Common Emergencies of

the Head and Neck

© 2005 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
 Auricular Hematoma
• Blunt trauma
– Shear injury at anterior auricular skin
– Contact sports, child abuse
• Hematoma
– Between cartilage/perichondrium
– Fluctuant anterior ear swelling
• Treatment
– Needle aspiration inadequate
– Incision & drainage recommended
– Compressive dressing
– Antistaph antibiotics
• Complications
– Infection/abscess
– “Cauliflower” ear Right Auricular Hematoma

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 Auricular Hematoma Treatment

Incision & Drainage with Bolsters

“Cauliflower” Ear
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 Complicated Otitis Media:
Suggestive Features
High-risk patient
• Neonate
• Immunocompromised state
– Diabetes, HIV, neutropenia
Intracranial
• Severe headache, fever
• Meningeal signs, seizures, ∆MS
Otologic
• Pain (retro-orbital, mastoid)
• Severe vertigo, SNHL
• Cranial nerve involvement (6,7,8)
• Displaced pinna

Coalescent Mastoiditis
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 Otitis Media: Complications

Otologic
• Mastoiditis/subperiosteal abscess
– Pain, swelling, discharge
– Displaced pinna
• Petrous apicitis
– Retro-orbital or mastoid pain
– Abducens palsy
• Labyrinthitis
– Severe vertigo, nystagmus, SNHL
• Facial paralysis

Subperiosteal Abscess
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 Otitis Media: Complications

Intracranial
• Meningitis
– Fever, meningeal signs
• Epidural abscess
– Fever, headache
• Sigmoid sinus thrombosis
– Spiking fevers, headache
• Brain abscess
– Subtle ∆MS
– Overt seizures, coma

Epidural Abscess

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 Idiopathic Sudden Sensorineural
Hearing Loss (SNHL)
• Hearing loss
– Sudden - no trauma history
– Rapidly progressive (<3 days)
• Etiology - unclear
– Viral » 30%-50% - recent viral URI
– Vascular - hypercoagulable state
– Membrane rupture
• Associated symptoms
– Aural fullness/tinnitus/vertigo
• Normal examination
– Ear Left SNHL
– Neurologic

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 Idiopathic Sudden Sensorineural
Hearing Loss
Workup - 90% no etiology found
• Complete audiogram
• CBC/platelets/ESR/RPR
MRI with gadolinium
• 1%-3% acoustic tumors
Management
• Urgent ENT referral
• Corticosteroids - proven benefit
• Other therapies - controversial
– Carbogen, Histamine, Heparin,
Dextran
Prognosis - 2/3 recover hearing
• Related to severity Left Acoustic Neuroma
• Improved if responsive to steroids

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 Temporal Bone Fracture
Blunt >> Penetrating
• MVA, assault, fall
• Associated with life-threatening injuries
Evaluation
• Trauma protocol/clear C-spine
• Assess facial nerve function early
– Immediate vs. delayed
• Ear examination - hemotympanum,
CSF, TM perforation
• Assess hearing-tuning forks, audiogram
• Radiology
– Head CT- evaluate for brain injury
– CT of temporal bone - with bone
windows Hemotympanum
• Evaluate extent of fracture

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 Temporal Bone Fracture
Physical Examination

Raccoon's Eyes External Canal Laceration

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 Temporal Bone Fracture
CT Findings

Longitudinal
Fracture

Transverse
Fracture

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 Temporal Bone Fracture Management

• Facial nerve paralysis

– Immediate - operative exploration and repair
– Delayed - observe, steroids, eye protection
• CSF leak - conservative management
– bed rest »» lumbar drain
– >90% resolve in 2 weeks
• Hearing loss
– Sensorineural - hearing aid
– Conductive- ossicular reconstruction
• Vertigo - treat symptomatically
– Meclizine, physical therapy

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 Acute Facial Paralysis

Idiopathic (Bell’s) Palsy >50%

Etiology
• Herpes simplex virus
• Neural edema in bony sheath
Acute onset
• Rapid time course
No hearing loss or vertigo
+/- Ear/facial pain
Normal examination
• Head and neck examination
• Neurologic examination
Facial paralysis workup
• CBC, ESR, Lyme titer
• Glucose tolerance test
• Audiogram
• CT/MRI - if atypical/recurrent
Diagnosis of exclusion
• Infectious
− Zoster, Lyme, otitis media
• Neoplasm
− Temporal bone, parotid
• Systemic
− Sarcoid, diabetes,
autoimmune

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 Acute Facial Paralysis
Physical Examination

Parotid Tumor Cholesteatoma

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 Acute Facial Paralysis
Physical Examination

Right Facial Palsy

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 Idiopathic (Bell’s) Palsy Management

• Corticosteroids/acyclovir
– Decreases sequealae
• Eye care - most important
– Educate patient
– Ocular lubricants
– Exposure protection
– Early ophthalmology consultation
• Prognosis - generally good
– 85% recover in 3 weeks
– 15% - delayed recovery (3-6 mos.)
– 10%-15% adverse sequelae
• Synkinesis and residual weakness

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 Acute Facial Paralysis Eye Care

Corneal Ulceration

Moisture Chamber

Lower Lid Tape

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 Herpes Zoster Oticus
Ramsay Hunt Syndrome
• Etiology - herpes zoster infection
– Analogous to shingles-geniculate
ganglion
• Severe pain with facial paralysis
• Vesicular eruption - ear/face/palate
• Hearing loss/vertigo - 10-40%
• Management
– Corticosteroids, acyclovir
– Analgesics, topical antibiotics
– Eye care
• Prognosis - worse than Bell’s
– 60% - normal recovery
– Worse if paralysis is complete

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 Otitis Externa
• Pain, fullness, itching, hearing loss
• Water exposure, canal trauma, otitis
media
• Pseudomonas, proteus, Staph, fungal
• Treatment
– Frequent thorough cleaning
• +/-wick placement
– Ototopical agents- most important
– Oral antibiotics- cellulitis/
lymphadenopathy
– Analgesics/nonsteroidal anti-
inflamatory drugs (NSAIDs)
– Patient education
• Water precautions
• Ear cleaning instruction

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Otitis Externa Physical Examination

Otitis Externa Otomycosis

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 Necrotizing Otitis Externa
• Osteomyelitis of the skull base
– Pseudomonas predominantly
• Immunocompromised/diabetic
patients
– Severe pain/discharge
– Granulation tissue in ear canal
– Cranial neuropathies - 7,9,10,11
• CT/nuclear medicine scan
• Long-term intravenous antibiotics
– Antipseudomonals
• Prognosis- 60% mortality
– Related to response to therapy
Granulation in External
Auditory Canal
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 Epistaxis

• Very common
– 60%-70% - one episode
– 10% - seek medical attention
– 6%-10% require ENT consultation
– Seasonal incidence
• Winter >> Summer

• Potentially life threatening

• Etiology
– Trauma, bleeding disorder, tumor
– Septal deviation, foreign body
• Site of bleeding
– Anterior (90%), Posterior (10%)

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 Epistaxis: Etiology

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 Epistaxis: Acute Management

• History
– Side, duration, estimate blood loss
– PMH - HTN, liver & hematologic disease
– Medications - aspirin, NSAIDs, Coumadin
– Previous epistaxis history
• Examination
– Vital signs and orthostatics
– General examination - purpura, petechia
– Nasal examination
• Head-light, suction, universal precautions
• Remove clots, decongest nose
• Determine bleeding site

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Epistaxis: Acute Management Equipment

© 2005 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
 Epistaxis: Acute Management
• Reassure patient
• Control hypertension
• Labs: complete blood count, prothronebin/partial
thromboplastin time, platelets, type & cross
• Treatment - depends on bleeding site
– Anterior epistaxis
• Cautery - silver nitrate
• Anterior packing - remember topical and oral antibiotics
– Posterior epistaxis
• Posterior packing
• Endoscopic cautery
• Arterial ligation - sphenopalatine, ethmoid
• Angiography/embolization
• ENT followup

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 Epistaxis: Acute Management

Septal Cautery Packing Placement

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 Epistaxis: Acute Management

Posterior Packing Endoscopic Artery Ligation

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 Nasal Fracture
• Very common
– Most common facial fracture
– 3rd most fractured bone
• High index of suspicion for fracture
– Mechanism, change in appearance
– Epistaxis, nasal obstruction
• Examine and palpate nose carefully
– Instability, mobility, crepitation
– Lacerations, septal hematoma
• Nasal x-rays - variable reliability
• Early ENT referral (<5 days)
– Closed/ open reduction - early
– Septorhinoplasty - late

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 Nasal Fracture Management

Nasal X-ray Closed Reduction

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 Nasal Fracture Complications

Septal Hematoma Septal Deformity

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 Zygoma Fracture

• Signs and symptoms

– Subconjunctival hemorrhage
– Infraorbital hypesthesia
– Depressed malar eminence
– Trismus/bony step-off
• Evaluation
– Facial CT - coronal cuts
– Ophthalmology evaluation
• Evaluate for ocular injury
• Management
– Open reduction/internal fixation

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 Zygoma Fracture Evaluation

Malar Depression
Plain X-ray
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 Zygoma Fracture Management

CT
ORIF
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 Orbital Floor Fracture Evaluation

Neutral Gaze

Left Orbital Floor Fracture

Upward Gaze
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 Mandible Fracture
• 1/3 - 1/2 facial fractures
• Signs and symptoms
– Malocclusion, step-off
– Floor of mouth hematoma
– Chin (V3) hypesthesia
• Evaluation
– Secure airway - as needed
– Rule out associated injury
• Closed head injury
• C-spine, facial fracture
• Tooth aspiration
– Panorex, mandible series
– CT

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 Mandible Fracture Radiology

Left Body Fracture Bilateral Condylar Fractures

© 2005 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
 Mandible Fracture

Management
• Soft diet - some fractures
– Pediatric, normal occlusion
– Nondisplaced
• Ramus, subcondylar
• Closed reduction (MMF)
– Minimally displaced
– Favorable anatomy
• Open reduction/internal fixation
– Most significant fractures
•Complications
– Infection/nonunion Right Parasymphyseal Fracture
– Malocclusion

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 Midface Fracture

• Diagnosis
– Malocclusion, depressed midface, open bite
– Assess midface mobility
– CT with axial and coronal cuts

• Management
– Secure airway - oral intubation if possible
• C-spine or laryngeal fractures - surgical airway
– Avoid nasal instrumentation - cranial penetration
– Recognize and treat closed head injury
– Brisk epistaxis common - posterior nasal packing
– Suspect CSF leak
– Open reduction and internal fixation

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 Midface Fracture

Epistaxis/CSF Rhinorrhea

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 Midface Fracture

Coronal CT Open Bite

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 Sinusitis: Orbital Complications

• Young children/ethmoiditis
• Signs and symptoms
– Lid edema, chemosis, proptosis
– Ophthalmoplegia, visual loss
• CT with contrast
– Subperiosteal abscess
– Orbital cellulitis vs. abscess
• Management
– IV antibiotics - Strep, Staph
– Ophthalmologic evaluation
– Surgery
• Ethmoidectomy
• Orbital drainage

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 Sinusitis: Orbital Complications

Orbital Cellulitis Subperiosteal Abscess

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 Sinusitis: Intracranial Complications

• Young adults - commonly

– Frontal or pansinusitis
– Meningitis, epidural /brain abscess
• Signs and Symptoms
– Severe headache, fever, ∆MS
– Nuchal rigidity, seizure, coma
• CT with contrast/MRI
• Lumbar puncture
• Urgent consultation
– ENT/neurosurgery

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 Sinusitis: Intracranial and
Local Complications

Brain Abscess Frontal Bone Osteomyelitis

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 Sinusitis: Immunocompromised
Host Complications

• Sinusitis common
– HIV/AIDS - 75%
– Chemotherapy/ neutropenia
• Signs and symptoms
– Fever, progressive symptoms
– Poor response to antibiotics
• Management
– Culture-directed therapy
– Early CT/IV antibiotics
– Infectious disease consultation

Middle Meatus Purulence

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 Sinusitis: Invasive Fungal
Rhinosinusitis Complications
• Immunocompromised patient
– Uncontrolled diabetic
– Oncologic patient (neutropenia)
• Few symptoms - discharge, pain
• Intranasal exam - blackened mucosa
• CT/ MRI to evaluate invasion
• Amphotericin B and debridement
• Prognosis - very poor
– Correct underlying immunodeficiency
• Control blood sugar
• Granulocyte stimulating factor

Necrotic Nasal Mucosa

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 Deep Neck Space Infections
• Source of Infection
– Pediatric - tonsil/sinus/otitis
– Adult - teeth/salivary gland/skin
– Unidentified source (50%)
• Signs and symptoms - depends on
space
– Fever, pain, swelling (>90%)
– Dysphagia, trismus (18%)
– Fluctuance - uncommon (27%)
• Microbiology
– Strep and Staph - most common
– Gram negative
– Mixed flora (40%)
– Anaerobes
Left Neck Abscess
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 Deep Neck Space Infections:
Management
• Secure airway - as needed
• CT scan with contrast
– Cellulitis vs. abscess
– Identifies neck space involved
• Cultures - blood and needle aspirate
• IV antibiotics
• Incision and drainage
– Obvious abscess
– Failure to improve on antibiotics
– Impending complication
• Complications
– Mediastinitis/ sepsis, internal jugular
vein thrombosis
– Osteomyelitis (mandible, C-spine),
– Cerebrovascular complications CT with Contrast
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 Retropharyngeal Abscess
• Young Children - predominantly
– Sinus/Adenoid source following URI
• Adults - Iatrogenic
• Symptoms - often subtle
– Fever, neck rigidity, dysphagia
• Lateral neck x-ray - screening
– Child - <7 mm @ level of C2
– Adult - <1/3 width of C2 body
• CT with contrast - definitive
• Management
– IV antibiotics
• Strep, Staph, anaerobes
– Incision and drainage - intraoral
Lateral Neck X-Ray
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Retropharyngeal Abscess Evaluation

False-Positive Lateral CT with Contrast

Neck X-ray

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 Peritonsillar Abscess

• Diagnosis
– Adolescents/young adults
– Progressive odynophagia (3-7 days)
– Fever/trismus - prominent
– Abscess adjacent to tonsil
• Edema, erythema, uvular
Deviation
• Tonsil displaced medially (80%)
• Management
– Drainage - needle aspiration,
incision & drainage
– Antibiotics - Strep
– Hydration/analgesics/followup
Right PTA
– Consider tonsillectomy

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 Ludwig’s Angina

• Submandibular/sublingual infection
– Odontogenic source (70%)
– Edema/induration - floor of mouth
• Management
– Secure airway early
• Rapid progression common
• Respiratory distress (>25%)
– Panorex/CT with contrast
• Determine source and extent of
infection
– IV antibiotics - Strep, anaerobes
– Incision & drainage +/- tracheotomy

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 Ludwig’s Angina Radiology

Periapical Abscess Submandibular Abscess

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 Angioedema

• Acute painless mucosal edema

– Face, lips, tongue, larynx
– Airway obstruction - 20%
• Etiology
– ACE Inhibitor - most common
– Hereditary angioedema - rare
– Idiopathic - unknown trigger (allergic reaction?)
• Aggressive early treatment required
– Secure airway early
– Epinephrine, corticosteroids, antihistamines
– Discontinue ACE inhibitors
• Medical consult - blood pressure control

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 Angioedema Clinical Presentation

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 Foreign Body Aspiration

• History very important

– Young child - 75% <3 years old
– Paroxysm of coughing
– Nuts, plastic toy, popcorn
• Examination - negative (40%-50%)
• Radiology- 80% radiolucent
– Chest x-ray normal (10%-34%)
– Inspiratory/ expiatory x-ray
– Fluoroscopy
• Rigid bronchoscopy
– Diagnostic and therapeutic

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Foreign Body Aspiration Evaluation

Left Bronchus
Foreign Body

Inspiration Expiration
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 Foreign Body Aspiration Evaluation

Right Lower Lobe Atelectasis Right Bronchus Foreign Body

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 Esophageal Foreign Body
• Children • Adult
– Symptoms often subtle – Diagnosis straightforward
– Drooling, sore throat – Associated esophageal
– Coin (#1), Food pathology
– Fishbone, meat, denture
• Chest x-ray - if radiopaque
• Esophagogram
– Site of obstruction/ impaction
– Demonstrate stricture or pathology
– BEWARE!! Aspiration risk if total
obstruction
• Rigid esophagoscopy with removal
– Recommended therapy
– Disk battery- urgent esophagoscopy

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Esophageal Foreign Body Evaluation

Coin at Cricopharyngeus Partial Dental Plate

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 Caustic Ingestion
• Children - most common, accidental
• Adults - suicide attempt
• Do not induce vomiting
• Determine - brand name/quantity ingested
– Call Poison Control Center
– Alkali worse than acid
Esophageal
• Exam not predictive of severity Stricture
– Most without oral lesions
• Urgent specialty consultation
– Flexible laryngoscopy
– Esophagogram
– Esophagoscopy - early

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 Blunt Laryngeal Trauma
• Mechanism - MVA, sports, assault
• Signs and symptoms
– Hoarseness, voice change, Stridor
– Subcutaneous emphysema,
hemoptysis
• Secure airway
– Oral intubation - problematic
– Tracheotomy (not cricothyrotomy)
• Flexible fiberoptic laryngoscopy
• CT scan - evaluate skeletal
derangement
Minimally Displaced Thyroid
Cartilage Fracture
• Surgical exploration/repair (<72 hours)

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 Blunt Laryngeal Trauma Evaluation

Flexible Laryngoscopy Right Vocal Fold Hematoma

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 Blunt Laryngeal Trauma
Indications for CT

• Significant voice alteration

• Edema or hematoma on endoscopy
• Laceration or blood on endoscopy
• Vocal fold paralysis
• Palpation suspicious for fracture
• After tracheotomy
– Before definitive treatment

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Blunt Laryngeal Trauma Management

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 Penetrating Neck Trauma
• Secure airway/clear C-spine
• Assume multiple injuries
• X-rays - neck and chest
– Foreign bodies, pneumothorax
– Bony trauma, trajectory
• Weapon - knife (55%), gun (38%)
• Determine zone
– 1 - below cricoid (16%)
– 2 - cricoid to angle of mandible (78%)
– 3 - above angle of mandible (6%)
Gunshot Wound
Left Level 1

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 Penetrating Neck Trauma Management

Hemodynamically Stable Hemodynamically Unstable Delayed Presentation

Minimal Findings

Zones I, III Zone II Neck Exploration Observation

Diagnostic Evaluation Neck Exploration

Angiogram Or
Esophagram Workup as in Zone I, III
Flex Laryngoscopy

Positive Evaluation Negative Evaluation

Neck Exploration Observation

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 Penetrating Neck Trauma:
Patterns of Injury
Vascular Injury
• Carotid injury (11%-13% of gunshot
wounds)
• Signs/symptoms
– Neurologic deficit - 1/4
– Expanding hematoma - 2/3
– Clinically silent - 15%
• Arteriogram - 97% sensitive
– Rarely false negative
– Embolization possible
• Zone 1, 3, and vertebral
artery
• Complications
– Stroke, exsanguination Carotid Aneurysm
– Pseudoaneurysm, arteriovenous
fistula
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 Penetrating Neck Trauma:
Patterns of Injury
Pharynx/esophagus - 10%
• Pain, dysphagia, hematemesis
– Commonly silent (25%)
• Barium swallow/esophagoscopy
• Complications
– Mediastinitis/sepsis, fistula

Larynx/ Trachea - 9%
• Hoarseness, stridor, hemoptysis
– Usually obvious
• Laryngoscopy/bronchoscopy
• Complications
– Laryngeal dysfunction, stenosis
Neck Emphysema
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 Upper Airway Obstruction
Initial Assessment
• Determine severity
– Physical examination - assess level of dyspnea
• Rate, anxiety/agitation, stridor, retractions, cyanosis
• Determine need for acute intervention
– Pulse oximetry/arterial blood gas - normal until collapse
imminent
– Flow volume loop - chronic progressive obstruction
• Determine site of lesion
– Stridor - inspiratory, expiratory, biphasic
– Associated symptoms- indicate site of obstruction
• Hoarseness, dysphagia, odynophagia, hemoptysis
• Referred otalgia, positional dyspnea, feeding problems
– AP/LAT neck films, chest x-ray, CT - often helpful
– Flexible fiberoptic laryngoscopy - most direct

© 2005 The American Academy of Otolaryngology – Head and Neck Surgery Foundation
 Upper Airway Obstruction
Site of Obstruction
• Above Larynx
– Retropharyngeal or Deep Neck Abscess
– Facial Fracture, Cervical Hematoma
• Supraglottis
– Laryngomalacia, Epiglottitis
– Carcinoma
• Glottis
– Vocal Cord Paralysis, Intubation Trauma
– Larynx Fracture, Angioedema
– Juvenile Papillomatosis, Carcinoma
• Below Glottis
– Croup, Subglottic Stenosis
– Tracheal or Mediastinal Tumor

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Upper Airway Obstruction Evaluation

Tracheal Deviation Subglottic Mass

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 Upper Airway Obstruction Evaluation

Subglottic Stenosis Laryngeal Papilloma

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 Upper Airway Obstruction

Initial Management Oral Intubation

• Supplemental oxygen • Ideal first-line management
• Nebulizers/aerosols • Technique familiar
• Parenteral steroids • Assemble personnel and
• Heliox equipment
• Artificial airway • Relative contraindications
– Oral – Oral/laryngeal trauma
– Nasal – Severe midface trauma
– C-spine injury

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 Upper Airway Obstruction
Awake Fiberoptic Intubation
Difficult anatomy
• Trismus, morbid obesity
• History of difficult intubation
• Tongue base swelling or tumor
Technique
1. Anesthetize nose
2. Place endotracheal (ET) tube in nose
3. Place scope through ET tube
4. Anesthetize larynx/trachea
5. Advance scope into trachea
6. Advance ET tube over scope

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 Upper Airway Obstruction
Surgical Airway

Cricothyrotomy

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 Upper Airway Obstruction
Algorithm of Management

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 Inflammatory Laryngeal Disease:
Clinical Features
Croup Epiglottitis

Etiology Viral Bacterial

Age 1-3 years 2-8 years
Symptoms Barking cough Hot potato voice
Stridor Biphasic Inspiratory
Fever Low Grade High
Oral intake Good Poor
Onset Gradual Rapid

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 Inflammatory Laryngeal Disease:
Croup vs. Epiglottitis

Subglottic Narrowing Epiglottic Swelling

© 2005 The American Academy of Otolaryngology – Head and Neck Surgery Foundation