Crisis Guide

Otolaryngology

Editors:
Jodi D. Zuckerman, M.D.
G. Aaron Rogers, M.D.

1
 Table of contents
Table
of contents
About this Text 4
About the Authors 5
Introduction 6

I: Common ENT Infections

Section I: Common ENT Infections 8

Acute Otitis Media & Mastoiditis – Oswaldo Henriquez, M.D. 8-9

Necrotizing Otitis Externa – Ajani Nugent, M.D. 10-11
Complications of Acute Sinusitis – Praveen Duggal, M.D. 12-13
Invasive Fungal Sinusitis – Anita Sethna, M.D. 14-15
Acute Tonsillitis and Peritonsillar Absess – Elina Kari, M.D. 16-17
Epiglottitis & Supraglottitis – Jodi D. Zuckerman, M.D. 18
Retro- & Parapharyngeal Infections – Frederick Durden, M.D. 19

II: Trauma
Ludwig’s Angina – Eric Berg, M.D. 21-22
Deep Space Neck Infections – Elina Kari, M.D. 23-24

Section II: Trauma 26

Nasal Septal Hematoma – Avani Ingley, M.D. 26-27

Auricular Hematoma – Adrienne Laury, M.D. 28-29

III: Operative Complications

Mandibular Fractures – Eric Berg, M.D. 30-31
Orbital Floor Fractures – Casey Mathison, M.D. 32-33
Frontal Bone Fractures – Lindsey Arviso, M.D. 34-35
Temporal Bone Fractures – Grace Leu, M.D. and Aaron Rogers, M.D. 36-37
Blunt Laryngeal Trauma – Aaron Rogers, M.D. 38-39
Penetrating Neck Injury – Shatul Parikh, M.D. and Jodi D. Zuckerman, M.D. 40-41
IV: Miscellany

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Table of contents 2
 Table of contents
I: Common ENT Infections
Section III: Operative Complications 42

Post-Tonsillectomy Hemorrhage – Clyde Mathison, M.D. 42-43

Carotid Blowout – Ajani Nugent, M.D. 38 44-45
Tracheostomy Bleeding – Iman Naseri, M.D. 46-47
Flap Compromise – Craig R. Villari, M.D. 48-49
Cervical Hematoma – Candice Colby, M.D. 50-51
Pharyngocutaneous Fistula – Katherine Hayes, M.D. 52-53
Hypocalcemia – Aaron Rogers, M.D. 54-55

II: Trauma
Cerebrospinal Fluid Leaks – Eric Berg, M.D. 56-57
Orbital Hematoma – Kara Prickett, M.D. 58-59

Section IV: Miscellany 60

Epistaxis Lindsey – Arviso, M.D. 60-61

Angioedema – Jodi Zuckerman, M.D. 62-63

III: Operative Complications

Inhalational Injuries – Elizabeth Hoddeson, M.D. 64-65
Facial Nerve Paralysis – Craig R. Villari, M.D. 66-67
Sudden Sensorineural Hearing Loss – Praveen Duggal, M.D. 68-69
Foreign Bodies – Avani Ingley, M.D. 70-71
Tracheostomy Care – Anita Sethna, M.D. 72-73
Ventilating Bronchoscope Setup 74-75
IV: Miscellany

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3 Table of contents
 Table of contents
About
the text
This book is a collection of straighforward management strategies for
common ENT urgencies. It was written and edited by the residents
of the Emory University Department of Otolarygology – Head & Neck

I: Common ENT Infections

Surgery. This collection was originally created as a pocket reference for
acute treatment of common ENT emergencies; it is not meant to be an
all-inclusive text. The opinions and recommendations offered here are
loosely collected from our training experience as well as the prevailing
opnion in recent literature and major otolarygology texts.

II: Trauma
III: Operative Complications
IV: Miscellany

Crisis guide: Otolaryngology

About the text 4
 Table of contents
About
the authors
Jodi D. Zuckerman, M.D.
is an otolaryngologist in private practice in Chicago, Illinois after
completing her residency at Emory University in Atlanta, Georgia.

I: Common ENT Infections

G. Aaron Rogers, M.D.
is pursing general otolaryngology and rhinology after completing
residency at Emory in 2010.

Drs. Anita Sethna and Frederick Durden

are currently in Facial Plastics and General Plastics fellowships
after completing residency in 2009 at Emory.

Drs. Avani Ingley and Casey Mathison

will complete residency training in 2010 at Emory.

Drs. Lindsey Arviso, Eric Berg, and Elina Kari

II: Trauma
will be completing residency in 2011 at Emory.

Drs. Oswaldo Henriquez, Praveen Duggal, and Ajani Nugent

will be completing otolaryngology residency in 2012 at Emory.

Drs. Colby, Hoddeson, Prickett, Villari, Laury, and Hayes

will be completing otolaryngology residency in 2013 and 2014 at Emory.

III: Operative Complications

Dr. Iman Naseri
is a 2008 Emory Otolaryngology graduate, and is now Assistant
Professor of Otolaryngology – Head & Neck Surgery at the University
of Florida (Jacksonville).

Drs. Shatul Parikh and Grace Leu are also graduates of the 2008
residency class at Emory are currently in private practice in Atlanta,
Georgia and Fresno, California (respectively).
IV: Miscellany

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5 About the authors
 Table of contents
Introduction

I: Common ENT Infections

Otolaryngology is an exciting field that usually allows
for the practice of surgery and medicine in a controlled
environment. However, like any medical field there
are an abundanceof emergencies that require focused
attention and rapid decision-making. In a crisis, the
effective practitioner should be able to assimilate all
available data and make clear decisions aimed at
stabilizing an emergency.

II: Trauma
III: Operative Complications
IV: Miscellany

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introduction 6
 Table of contents
I: Common ENT Infections
II: Trauma
III: Operative Complications
Mission

Together with our customers

we are driven
to make healthcare better.
IV: Miscellany

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7 introduction
 Table of contents
Section I:

Common ENT Infections

Acute Otitis Media and Mastoiditis

Oswaldo Henriquez, M.D.

I: Common ENT Infections

Clinical presentation of acute otitis media includes otalgia, fever, hearing loss, ear
pulling and irritability, and upper respiratory symptoms. Upon otoscopic
examination there can be appearance of thickening and erythema of the
tympanic membrane, perforation with suppurattive otorrhea in the auditory
canal, decreased visibility of middle ear landmarks, decreased tympanic mobility
on pneumatic otoscopy, and presence of middle ear effusion. In most cases,
clinical diagnosis should be sufficient alone. The three most commonly involved
bacteria are Streptococcus pneumonia, Haemophilus influenzae, and Moraxella
catarrhalis. In many cases Staphylococcus aureus and Pseudomonas

II: Trauma
aeurginosa may be identified.

Primary treatment of acute otitis media includes oral antibiotics to cover the above
common pathogens as well as analgesia. Usually primary treatment is with
amoxicillin or bactrim, or with amoxicillin + clavulante for persistent or recurrent
infections. General recommendations are for a 10-14 day course of PO therapy

III: Operative Complications

for uncomplicated AOM. Recent large studies in the primary care literature
advocate a “watch and wait” approach to treatment where antibiotics may be
withheld for up to 3 days to allow for spontaneous resolution.

IV: Miscellany

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Section 1: Common ENT infections 8
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Complications of AOM are classified as intratemporal or intracranial.
Intratemporal complications include coalescent mastoiditis, subperiosteal
abscess, facial nerve paralysis, labyrinthine fistula, or abscess at the temporal

I: Common ENT Infections

root, petrous apex, or mastoid tip. Intracranial complications include
meningitis, sigmoid thrombophlebitis, subdural empyema, epidural abscess,
parenchymal abscess, and otic hydrocephalus.

Masoitditis is basically the spread of otitis media infectious process to the mastoid
air cells. On physical exam there is presence of bulging erythematous tympanic
membrance with erythema, tenderness, and edema over the mastoid area,
and the classic protruding auricle. The work up includes a high-resolution CT
scan of the temporal bone. On CT there should be presence of middle ear

II: Trauma
effusion with coalescent mastoid air cells or attenuation of the bony mastoid
cortex. It is important to note that due to normal communication of the middle ear
and mastoid cavity, any OM can demonstrate a fluid filled mastoid
on imaging. MRI or contrast-enhanced CT can be helpful if there is
concern for intracranial complications.

III: Operative Complications

Treatment of mastoiditis can be medical or surgical depending on the severity
of the infection. Usually these patients are admitted for antibiotic therapy, most
commonly empiric vancomycin and ceftriaxone. Routine tympanostomy will aid
in treatment and in diagnosis. Mastoidectomy is usually considered for failure
of medical management or significant intracranial or intratemporal complications,
based on clinical and radiologic findings. Often collaboration with neurosurgery
or infectious disease specialties are necessary.
IV: Miscellany

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9 Section 1: Common ENT infections
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Necrotizing Otitis Externa
Ajani Nugent, M.D.

Necrotizing Otitis Externa (NOE, aka malignant otitis externa) is best viewed
as being an osteomyelitis of the temporal bone and skull base. The populations
most at risk are those with compromised immunity and diabetes.

I: Common ENT Infections

Infections leading to NOE are most commonly caused by Pseudomanonas
aeruginosa. It usually colonizes the EAC after exposure to water or minor
trauma. Fungal NOE, especially Aspergillus fumingatus, can be seen in the
HIV+ population.

Granulation tissue is usually found along the floor of the isthmus (bonycartilagenous
junction). Spread to the skull base can occur via the fissures
of Santorini and the tympanomastoid suture; the stylomastoid foramen and

II: Trauma
the jugular foramen are potentially affected.

Patients with NOE often present complaining of severe throbbing otalgia that
is present for several weeks and is refractory to analgesics. There is
commonly a prior history of benign otitis externa. Patients may also
complain of headache, TMJ pain, trismus, and conductive hearing loss.

III: Operative Complications

Visualization of the EAC and TM are necessary for diagnosis. Usually the EAC
will require debridement. Granulation on the floor of the EAC at the bony-cartilaginous
junction is nearly pathognomonic for NOE. Examination of cranial
nerve function is also requisite for assessment of any intratemporal infection.
IV: Miscellany

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Section 1: Common ENT infections 10
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Workup should include WBC and ESR in addition to imaging of the temporal
bone. Traditionally, Tc-99m nuclear scanning of the temporal bone is used
establishing the diagnosis of osteomyelitis and serial Ga-67 imaging used to

I: Common ENT Infections

follow for resolution. However, in the acute setting, high-res CT scanning
with contrast is often the most accessible and useful. Cultures taken from
the EAC may be useful but should not delay treatment. Serum glucose and
Hb1AC as well as an immunocompetency workup should be considered.

Topical fluoroquinolones and oral ciprofloxin are the most commonly

prescribed antibiotic regimen. However the use of ototopicals in NOE
is debated. Additionally frequent aural toilet (usually with microscopy) is
required. Surgery is generally not required acutely, but should be considered

II: Trauma
for fluid collections or significant skull base necrosis.

The suggested treatment regimen involves Ciprofloxin 750mg BID for a course
of 6-8 weeks. With intravenous administration reserved only for rare cases of
recalcitrant disease, often due to resistant Psuedomaonas. Particular
emphasis should also be placed on controlling hyperglycemia or any

III: Operative Complications

underlying immunosupression as well.

IV: Miscellany

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11 Section 1: Common ENT infections
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Complications of Acute Sinusitis
Praveen Duggal, M.D.

Sinusitis is the infection and inflammation of the paranasal sinus cavities.

The usual process of events stems from an upper respiratory infection that causes
increased mucosal secretions, edema, and blockage of sinus outflow tracts.

I: Common ENT Infections

Common symptoms of acute sinusitis include: purulent nasal discharge, facial pain
and pressure, headache, fever, cough, hyposmia, and otalgia. Causative organisms
include Streptococcus pneumonia, Haemophilus influenza, and Moraxella catarrhalis.
Most often bacterial sinusitis can be treated with antibiotics (eg. Fluorquinolones,
amoxicillin+clavulonic acid, cephalosporins, or sulfa derivatives) for 10-14 days.

Complications of acute sinusitis can be classified as orbital, intracranial, or both.

II: Trauma
Most infections can begin with facial erythema, periorbital edema, and tenderness.
Later worrisome symptoms include proptosis, chemosis, vision change,
ophthalmoplegia, and bilateral involvement.

Evaluation of orbital involvement includes a good history, evaluation of extraoccular

movements, visual acuity, and imaging with CT or MRI. Imaging is indicated with

III: Operative Complications

orbital symptoms, failure of antibiotics, or evaluation of suspected subperiosteal
abscess. MRI is more helpful if concern for intracranial complications.

Intracranial complications include meningitis, epidural abscess, subbural abscess,

intracerebral abscess, frontal osteomyelitis (Pott’s Puffy Tumor), and cavernous
(or other venous) sinus thrombosis. Symptoms including altered mental status,
cranial nerve palsies, nuchal rigidity, hearing loss, vomiting, and lethary should all
be assessed. Medical management with IV antibiotics along with surgical intervention
should be considered.
IV: Miscellany

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Section 1: Common ENT infections 12
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Orbital Complications of Sinusitis

Common Findings Treatment

I: Common ENT Infections

Preseptal Swollen eyelids; Medical therapy
cellulitis extraocular muscles (EOM) (rarely, drainage of
intact; normal vision secondary abscess)
Orbital More diffuse orbital Medical therapy
cellulitis edema; ± impaired EOM; ± sinus drainagea
usually normal vision
Subperiosteal Proptosis; impaired EOM Medical therapy;
abscess ± sinus drainage,
± abscess drainage
Orbital Severe exophthalmos, Medical therapy; sinus
abscess chemosis, complete drainage, often; abscess

II: Trauma
ophthalmoplegia and drainage, usually
visual impairment common
Cavernous sinus Bilateral orbital pain, Medical therapy;
thrombophlebitis chemosis, proptosis, sinus drainage, often;
and ophthalmoplegia ± anticoagulation

*Adapted from Chandler JR. The pathogenesis

III: Operative Complications

of orbital complications in acute sinusitis.
Laryngoscope. 1970; 80:1414-1428

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13 Section 1: Common ENT infections
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Invasive Fungal Sinusitis
Anita Sethna, M.D.

Acute invasive fungal sinusitis constitutes a surgical emergency due to its

ability to progress rapidly. Different from allergic fungal sinusitis, this entity can
carry with it a mortality rate of 50-80%. The fungi involved invade deep into

I: Common ENT Infections

the sinuses, nasal mucosa and soft tissues surrounding the sinuses such as
the brain and orbits.

Fungal organisms are not uncommon in the nasal cavity. The reason
people suffer from IFS is most commonly due to a compromised
immune system. This can be from neutropenia secondary to
hematologic malignancy, chemotherapy, or even diabetics with poor
glucose control. The fungi that affect those with IFS are common
to the environment: Rhizopus, Mucor, and Aspergillus.

II: Trauma
Symptoms of this condition can be similar to bacterial sinusitis, such as fever
or facial pain. In particular, while examining a patient suspected of IFS, make
sure to assess cranial nerve function including gross vision, sensation over
the face and extra-ocular movements. Inspect the hard palate and oral cavity
in general.

On examination of the nose, look for necrotic, black tissue, mold spores, or

III: Operative Complications

any areas that appear paler than the surrounding tissues. The first areas to be
involved are commonly the middle turbinates and septum. Classic teaching
states the disease should be unilateral, but this is not always the case.

Radiologic imaging, CT of the sinuses without contrast, is helpful in visualizing

areas beyond traditional bedside endoscopy, and can give hints as to where
the disease may be originating. For example, changes in the retro-antral
tissues showing obliteration or increased soft tissue replacing fat planes
compared to the normal side, thickening of the nasal septal tissue, and a later
finding of bony destruction.
IV: Miscellany

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Section 1: Common ENT infections 14
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Workup Essentials:

1. Check labs for neutropenia/BG levels (ANC<250=neutropenia,

I: Common ENT Infections

but don’t exclude functional neutropenia).

2. Look at films for retro-antral fat thickening, bony destruction, unilateral

disease, nasal mucosa abnormalities, soft tissue inflammation.

3. Scope patient: a straight scope distorts less—try to avoid decongestant

because this may make tissues look pale falsely.

4. Do not random biopsy—but take a biopsy of anything suspicious

II: Trauma
for ischemia, necrotic black tissue or moldy appearing tissue. Call
in pathology for frozen section.

5. Place specimen on a piece of gauze and into a sterile specimen cup

(without formalin); place a few drops of saline to keep tissue moist and
take to pathologist.

III: Operative Complications

IV: Miscellany

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15 Section 1: Common ENT infections
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Acute Tonsillitis and Peritonsillar Abscess (PTA)
Elina Kari, M.D.

Patients in any age group can present with tonsillitis, where as the peritonsillar
abscess is usually seen in patients 20-40 years old. The patient will usually
complain of severe sore throat, odynophagia, dysphagia, drooling, malaise,

I: Common ENT Infections

referred otalgia, and fever. On physical exam there will be erythema and
edema of anterior pillar, trismus, drooling, “hot potato voice”, fluctuance,
inferior displacement of tonsil, and deviation of uvula/soft palate to contralateral
side. Tonsillitis will have inflammation of the actual tonsil with purulence but
no edema of the anterior pillar.

Causative agents include anaerobic and aerobic organisms. Streptococcus

species (especially Group A β-hemolytic Strep, Streptococcus pyogenes)
are most common. Anaerobic species: Prevotella species and Peptostreptococcus

II: Trauma
species can also be seen.

The differential diagnosis includes peritonsillar cellulitis, infectious mononucleosis,

retropharyngeal or parapharyngeal abscess, retromolar abscess, and neoplasia.
Complications include: airway obstruction, ruptured abscess and aspiration,
parapharyngeal abscess, glottic edema, poststreptococcal sequelae, and

III: Operative Complications

possible sepsis.

A CT scan is NOT needed for diagnosis of PTA in an adult who can open
their mouth. CT scans will show a fluid collection medial to superior
pharyngeal constrictor muscles. Consider if diagnosis of PTA is equivocal.
The otolaryngologist needs the following equipment for successful treatment
of a PTA: tongue blade, head light, yanker suction, 10 cc syringe, 1%
lidocaine with epinephrine, hurricane spray, 18 gauge needle, #15 blade,
hemostat, and culture swabs.
IV: Miscellany

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Section 1: Common ENT infections 16
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To treat, always remember your airway first. If there is obvious fluctuance,
attempt drainage with #18 gauge needle aspiration. Spray Hurricane spray
and infiltrate locally with 1% lidocaine + epinephrine. Aim for the superior pole

I: Common ENT Infections

of the tonsil or supratonsillar fossa. If you are not able to aspirate with needle,
you may consider I+D with #15 blade followed with hemostat dissection to
break up loculi. Take care to incise over an area that you have previously
needled to ensure you are not near the carotid artery.

Patients should receive IV antibiotics and be discharged on a 7-10 day course

of oral antibiotics. Tonsillitis patients may be discharged on clindamycin or
augmentin. For a PTA the same antibiotics can be used. Steroids may
be administered IV and a short course of steroids has been proven to help

II: Trauma
with trismus and pain upon discharge. Patients can be managed on an
outpatient basis if patient does NOT show signs of toxicity, sepsis, airway
compromise, or has significant co morbidities and is able to stay wellhydrated.
Close follow-up within a few days is advised for patients with a
true peritonsillar abscess. Patients with recurrent episodes are candidates
for tonsillectomy performed 4-6 weeks after resolution of PTA and is usually

III: Operative Complications

recommended with a patient that has had 2 or more episodes of PTA. A
Quincy tonsillectomy is a tonsillectomy performed during acute episode and
is indicated for severe airway obstruction or failed incision and drainage.

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17 Section 1: Common ENT infections
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Epiglottitis & Supraglottitis
Jodi D. Zuckerman, M.D.

Epiglottitis is an inflammation of the epiglottis, whereas supraglottitis is

swelling of the surrounding structures including the aryepiglottic folds
and arytenoid soft tissue. Epiglottitis is often seen in the pediatric patient,

I: Common ENT Infections

whereas supraglottitis is more commonly seen in the adult.

Causative organisms include: Haemophilus influenza, Klebsiella pneumonia,

Candida albicans, Staphylococcus aureus, Neisseria meningitides,
and varicella zoster. Caustic burns and trauma to the larynx can also
trigger acute inflammation in the supraglottic structures.

Patients will present with drooling, dysphagia, respiratory distress,

and possible stridor.

II: Trauma
This is considered a surgical emergency and again the otolaryngologist
must ensure a secure airway before further workup is pursued.
Patients stable enough for laboratory and imaging may demonstrate
a peripheral bandemia and “thumbprint sign” on lateral neck X-ray.

III: Operative Complications

The key to management of this disorder is quick recognition (based on
presenting signs and symptoms) and securing the airway early. Many of
these patients can undergo awake fiberoptic intubation with the otolaryngologist
on standby for an emergency tracheostomy. Classically however, great
caution is required during any stimulation of the airway as this may trigger
an acute decompensation.

After the airway is secured broad spectrum antibiotics are usually begun.
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Section 1: Common ENT infections 18
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Retropharyngeal and Parapharyngeal Infections
Frederick Durden, M.D.

Retropharyngeal and parapharyngeal space abscesses can be common

consults for the ENT physician. The parapharyngeal space is bounded by
the parotid gland and mandible laterally, pharynx and pterygoid muscles

I: Common ENT Infections

medially, superiorly by the skull base and inferiorly by the hyoid bone.
Spaces are then separated by the pre- and post- styloid compartments.
The prestyloid space contains the maxillary artery, inferior alveolar, lingual
and auriculotemporal nerves. The poststyloid space contains cranial nerve
IX, X, XI, sympathetic chain, internal jugular vein and carotid artery.

Infections of the parotid and odontogenic sources can spread to this space.
Any virus or upper respiratory infection that has significant lymphadenopathy
can futher develop into a parapharyngeal space infection. Complex peritonsillar

II: Trauma
abscesses can also further develop into parapharyngeal space infections.

The retropharyngeal space is bounded by the pharyngeal constrictors

anteriorly, alar fascia posteriorly, skull base superiorly, and mediastinum
inferiorly. It contains lymphatic vessels draining from infections in the nose,
sinus, nasopharynx, and oropharynx.

III: Operative Complications

The organisms responsible for this infection in adults include:
Streptococcus viridans, S. aureus, Klebsiella pneumoniae,, Bacteroides
species, Staphylococcus epidermidis, Anaerobic Streptococci, E. coli,
Prevotela species, and Mycobacterium tuberculosis. In children, common
pathogens include: S. aureus, Haemophilus, B-hemolytic streptococcus,
Bacteroides species, Peptostreptococcus species, Fusobacterium
species, Prevotella species, and coagulase-negative Staphlococcus.
There has recently been an emergence of Methicillin Resistant Staph
Aureus and when this is the causative agent first line treatment usually
includes clindamycin or sulfamethoxazole/trimethoprim pending sensativities.
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19 Section 1: Common ENT infections
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Patients will present with fever, odynophagia, dysphagia, neck pain, poor oral
intake, lethargy and irritability. Large or advanced abscesses may impinge
on the airway causing respiratory distress and stridor. The physician should

I: Common ENT Infections

examine the oropharynx and look for oral pharyngeal bulge, or evidence of a
source of infection such as a peritonsillar abscess or odontogenic abscess.
Palpation of the neck may reveal cervical lymphadenopathy. A flexibile
laryngoscopy is helpful to determine effect on the airway and if emergent
management is warranted.

Treatment usually consists of airway stabilization, re-hydration, and broad

spectrum antibiotics covering gram positive and anaerobic organisms.
Mycobacterium tuberculosis can also be the causative agent for these

II: Trauma
abscesses and the patient should be placed on TB precautions and
treated appropriately.

If patients are not responsive to antibiotic treatment or there is a surgically

drainable abscess then incision and drainage may be necessary.
Parapharyngeal abscesses may be drained through the mouth with

III: Operative Complications

direct laryngoscopy. Evaluation of the great vessel position is imperative
prior to this approach. Most retropharyngeal and parapharyngeal abscesses
will be readily palpable in the neck and a simple incision and drainage with
drain placement is appropriate treatment.

IV: Miscellany

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Section 1: Common ENT infections 20
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Ludwig’s Angina
Eric Berg M.D.

Ludwig’s angina typically presents with rapid onset swelling of the floor of
mouth with elevation of the oral tongue, drooling, and possible airway
obstruction. It is the result of a rapidly spreading bilateral bacterial cellulitis

I: Common ENT Infections

of the sublingual, submental, and submandibular spaces. This infection may
spread through the buccopharyngeal gap (space created by the styloglossus
muscle as it passes between the middle and superior pharyngeal constrictors)
causing adjacent retropharyngeal and eventual mediastinal infection.

Risk factors include poor dentition, tooth extraction, floor of mouth trauma,
peritonsillar abscess, and intravenous drug abuse. In fact, ninety percent of
cases are odontogenic in origin with seventy-five percent originating from the
second and third manibular molars. Mortality rates approach 10% and are

II: Trauma
primarily due to airway compromise.

Evaluation of suspected Ludwig’s angina begins with a thorough physical

exam. Initial attention should be directed towards respiratory status and any
need for airway intervention. The exam should then be focused on the oral
cavity, oropharynx, and neck. Visualization of the oral cavity allows for

III: Operative Complications

assessment of oral airway patency. Teeth should be inspected for signs of
infection. Most importantly, the floor of mouth should be palpated. In Ludwig’s
angina, the floor of mouth takes on a firm, woody consistency and pushes
the tongue caudally. The displacement can extend to the base of tongue
and lead to further airway compromise. Fiberoptic laryngoscopy should be
utilized to better assess the patency of the oropharynx and hypopharynx.
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21 Section 1: Common ENT infections
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Radiographic evaluation consists primarily of computed tomorgraphy of the
neck with contrast. Findings range from diffuse inflammation and phlegmon
to frank abscess of the sublingual, submental, and submandibular spaces.

I: Common ENT Infections

Plain radiographs can be used to assess degree of soft tissue swelling and
caliber of the airway.

First and foremost, management should focus on the airway. Due to its rapid
progression, a once stable airway may quickly become compromised, and
one may consider securing the airway prior to this event. Frequent airway
reassessment should be performed to avoid sudden loss of the airway.
Oxygen should be provided as necessary. Should significant distress exist,
the airway should be first secured with an oral or nasal airway, intubation with

II: Trauma
or without fiberoptic guidance, or tracheostomy if necessary. Heliox may also
be considered. During airway evaluation, broad-spectrum antibiotics should
be administered to cover oral flora. Incision and drainage and tooth
extraction if an infectious focus is apparent may also be necessary.

III: Operative Complications

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Section 1: Common ENT infections 22
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Deep Neck Space Infections
Elina Kari, M.D.

Patients with upper respiratory infection, trauma, IV drug abuse,

tooth infections, oral infections, and immunosuppresion are all at risk for
deep neck space infections. Symptoms include sore throat, hoarseness,

I: Common ENT Infections

odynophagia, dysphagia, neck pain, stiff neck, fevers, and chills.

Signs include, neck asymmetry, mass, edema, erythema, crepitation,

tenderness to palpation, trismus, fever, cranial nerve deficits, tachypnea,
stridor, “hot potato” voice, tenderness over SCM, nuchal rigidity,
contralateral torticollis, ipsilateral Horner’s, vocal cord paralysis. Exam
should always include flexible fiberoptic laryngoscopy in any question of
possible airway compromise.

II: Trauma
Complications of a deep neck space infection include upper airway
obstruction, descending mediastinitis, pleural empyema, necrotizing fasciitis
of the head and neck, pericarditis, jugular vein thrombosis (Lemierre’s syndrome),
septic shock, carotid pseudoaneurysm or rupture.

The work up usually includes obtaining a CT scan with IV contrast to define

III: Operative Complications

the presence of an abscess with ring enhancing elements. MRI may be
used for soft tissue and nerve involvement. Laboratory work up includes:
CBC with differential, blood chemistries, blood cultures, coagulation and
clotting profiles, and abscess cultures.
To treat the abscess first and foremost, remember the airway. If the patient
has signs of respiratory distress, manage their airway first. Some patients with
severe deep neck infections may require an awake tracheostomy. Volume
and metabolic resuscitation, often requires ICU admission. Management of
deep neck infection varies depending on its location, extent, and severity.
Initial management with IV antibiotics is appropriate for small fluid collections
IV: Miscellany

in patients with no airway compromise.

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23 Section 1: Common ENT infections
 Table of contents
IV antibiotics should include coverage of gram positive bacteria, anaerobes, and
possible gram negatives. MRSA infection should be suspected and treatment
should include coverage against such resistant organisms. Surgery is reserved

I: Common ENT Infections

for patients who present with significant disease, airway compromise,
necrotizing fascitis, or for those who do not improve after 48h of IV antibiotics.
Keys to surgical treatment are wide exposure, multiple approaches and,
depending on the location, blunt dissection for drainage of the abscess cavity.
Necrotizing fascitis requires frequent debridement.

Relevant anatomy

• Visceral Space: (infrahyoid neck) space defined by the visceral layer

II: Trauma
of middle layer of deep cervical fascia. Space includes thyroid gland,
trachea, esophagus.

• “Danger” Space: Between alar and prevertebral fascia. Extends from skull
base to diaphragm. Contains sympathetic trunk and loose areolar tissue
and allows rapid spread of infection.

III: Operative Complications

• Prevertebral Space: Deep to prevertebral fascia, contains spinal cord and
extends from skull base to coccyx.

• Carotid sheath space: formed by other fascial layers, extends from skull
base to thoracic inlet. Contains carotid artery, jugular vein, vagus nerve.
IV: Miscellany

Crisis guide: Otolaryngology

Section 1: Common ENT infections 24
Table of contents I: Common ENT Infections II: Trauma III: Operative Complications IV: Miscellany

25
 Table of contents
Section II:

Trauma

Nasal Septal Hematoma

Avani Ingley, M.D.

I: Common ENT Infections

Septal hematoma often occurs as a result of nasal trauma. Bleeding occurs due
to bleeding, often bilateral, within the subperichondiral plane of the septum. Elevation
of the mucosa off the cartilaginous septum leads to a loss of septal vascular supply.
If the hematoma is not drained, fibrosis of the cartilage may occur, followed by
necrosis. Without treatment, in 3-4 days septal perforation will occur. The resultant
loss of septal support will lead to collapse of the nose and a saddle nose deformity.
A septal abscess may also develop if the collect clot becomes infected.

Treatment of a septal hematoma or abscess involves urgent drainage, which can

II: Trauma
be performed in the clinic or emergency department. An incision should be made
in the caudal septal mucosa and the hematoma evacuated. Consider placing a
small nasal tampon or splint to prevent reaccumulation of blood. The patient
should be seen in followup to observe healing and to remove any packing;
antibiotics are a must when packing or splints are placed.

III: Operative Complications

IV: Miscellany

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Section 2: Trauma 26
 Table of contents
I: Common ENT Infections
Bilateral septal hematoma.
Notice bulging septum,
often causing nasal
airway obstruction.
Dashed line marks incision
for drainage on the left.

II: Trauma
III: Operative Complications
IV: Miscellany

Crisis guide: Otolaryngology

27 Section 2: Trauma
 Table of contents
Auricular Hematoma
Adrienne Laury, M.D.

Auricular hematoma is a relatively common complication of direct trauma

to the ear or side of the head. It is most commonly seen in wrestlers and is
diagnosed by history and the loss of typical auricular landmarks on physical

I: Common ENT Infections

exam. The hematoma forms following a direct trauma as a result of the
tearing of perichondrial blood vessles. These sheared vessels then result in
a blood extravasation which separates the perichondrium from the anterior
auricular cartilage. If not repaired, multiple complications can arise including
infection, cartilaginous necrosis, and the most infamous – auricular chondropathy,
aka “cauliflower ear”.

Drainage of an auricular hematoma is fairly straightforward and should be

done in a timely fashion in order to prevent complications. The only

II: Trauma
contraindications to drainage include: hematoma presence >7 days or
recurrent/chronic hematomas. Begin drainage by placing the patient in a
lateral decubitus position on unaffected side. Cleanse area with antiseptic
and anesthetize ear with lidocaine without epinephrine. Next, make a small,
superficial incision approximately 5-10mm on the anterior portion of the ear
along a natural skin fold such as the helical rim. Separate the skinand

III: Operative Complications

perichondrium from the hematoma and cartilage and compress or suction
out the blood. Irrigate with saline. If possible, reapproximate the skin and
perichondrium with absorbable sutures.

A compression dressing must be placed over the ear; this is essential to

prevent reaccumulation of the hematoma. A simple dressing of bulky
vaseline gauze on both sides of the helix, secured in place with a matressed
heavy monofilament suture is most common and simplest. A circumfrential
dressign may also be applied.
IV: Miscellany

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Section 2: Trauma 28
 Table of contents
Oral antibiotics to cover for skin flora may be considered while the dressing
is in place. Reevaluate and remove the compression dressing in 2-5 days.
It is also important to remind the patient to avoid aspirin or NSAIDs as they

I: Common ENT Infections

may promote continued bleeding and reaccumulation of the hematoma.

I&D of Auricular Hematoma

(top image, dashed line indicates
possible incision site) followed
by placement of compression

II: Trauma
dressing (bottom image, gray
rectaongles represent gauze rolls
on either side of auricule secured
by heavy suture.

III: Operative Complications

IV: Miscellany

Crisis guide: Otolaryngology

29 Section 2: Trauma
 Table of contents
Mandibular Fractures
Eric Berg, M.D.

Fractures of the mandible are the second most common facial fracture
behind only nasal fractures. Because of the mobility of the mandible and
intimate involvement with the oral cavity, they have a relatively high complication

I: Common ENT Infections

and infection rate. The most common points of fracture are near the third
molar, the mental foramen, and at the condylar neck. In addition, bilateral
articulation at the temperomandibular joint makes bilateral fractures common.
Fractures are described as favorable versus unfavorable based upon the
muscular forces which serve to either reduce or displace fracture fragments.

Evaluation of a suspected mandibular fracture consists initially of a thorough

examination of the oral cavity and surrounding soft tissue. Note should
be made of signs of external trauma. Patients should be assessed for

II: Trauma
trismus and malocclusion. Anesthesia or parasthesias may be present if the
fracture involves the inferior alveolar nerve. Examination of the oral mucosa
may demonstrate gingival lacerations or a floor of mouth hematoma.

Radiographic evaluation consists primarily of computed tomography. It is

more sensitive in the diagnosis of mandible fractures than panoramic views

III: Operative Complications

however it may not show bony detail of alveolar ridge and tooth
fractures as well.

Most favorable fractures can be managed by closed reduction with maxillary

mandibular fixation alone. Four to six weeks is a sufficient duration for
symphysis, angle, and body fractures, however condylar fractures may
benefit from a shorter duration to preserve post-fixation range of motion.
IV: Miscellany

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Section 2: Trauma 30
 Table of contents
In spite of the simpler surgical approach of closed reduction, maxillary
mandibular fixation is very uncomfortable for patients, requiring a liquid diet
which may result in significant weight loss. Consideration of open reduction

I: Common ENT Infections

and internal fixation with plates alone may be appropriate for symphyseal,
parasymphyseal, angle, and body fractures. Ramus and condyle fractures are
often treated with closed reduction alone, as internal fixation is very difficult
to achieve and often requires an open or endoscopic approach. Special
consideration must be made in edentulous patients as arch bars are not an
option. Further, children are more often treated with closed reduction so as
to avoid growth disturbance.

Complications of fracture and management include infection, malocclusion,

II: Trauma
malunion, nonunion, TMJ ankylosis, TMJ dysfunction, trismus, tooth loss,
facial or inferior alveolar nerve damage, and poor cosmesis. To
minimize infectious risk, all open fractures should be treated with
perioperative antibiotics.
Surgical management need not be emergent provided the patient is able
to tolerate an oral diet and is often completed in an outpatient setting.

III: Operative Complications

Nevertheless, emergent management must be considered in cases of
airway obstruction, displacement of the condyle into the middle cranial
fossa, or hemorrhage.

IV: Miscellany

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31 Section 2: Trauma
 Table of contents
Orbital Floor Fractures
Casey Mathison, M.D.

Orbital floor fractures are a common result of facial trauma. They are usually
the result of blunt trauma to the face, such as an interpersonal altercation or
a motor vehicle collision. Presenting signs and symptoms can vary, and

I: Common ENT Infections

timing of surgical repair (if needed at all) depends on the physical exam
and radiographical findings.

Patients usually report being struck by a fist or a ball, or being in a car

accident. Typical complaints include facial swelling or pain, blurry vision,
diplopia (especially on up/down gaze), or numbness to the ipsilateral cheek.

The eye exam is the most important--you want to make sure that the globe
has not been injured. If any abnormalities are found, ophthalmology should

II: Trauma
be consulted. The patient should be assessed for stable vitals signs,
extraocular movements (may need to do forced duction), gross visual
acuity, papillary reactivity, enophthalmos or exophthalmos, hypoesthesia
to V2 distribution (cheek, teeth), gross facial asymmetry and depressions,
and subcutaneous emphysema. You will almost always see facial swelling
and ecchymosis.

III: Operative Complications

The work up includes a CT scan of the face with coronal reformats. Entrapment
of soft tissue, inferior rectus muscle, and fat should be evaluated on CT scan.
Other facial fractures (ZMC, mandible, frontal/maxillary sinus, temporal bone)
should be ruled out as well. Lastly, retro-orbital hematomas should be
followed with serial eye exams.
IV: Miscellany

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Section 2: Trauma 32
 Table of contents
Management of these fractures is almost always as an outpatient. Timing
of operative repair depends on finding physical exam and CT findings.
Indications for immediate surgical repair include: entrapment of extraocular

I: Common ENT Infections

muscles and non resolving oculocardiac reflex (bradycardia, heart block,
nausea, vomiting) caused by entrapped tissue. Repair can wait 7 to 14 days
when there are no immediate indications for repair and the swelling and
ecchymosis can resolve. If after swelling subsides repair may still be pursued
for cosmetic deformity and symptomatic diploplia. Patients can be observed
if there are no visual disturbances and less than 50% floor involvement.
Greater than 50% of the orbital floor involved with fracture has a high risk
for late enophthalmos if left untreated.

II: Trauma
III: Operative Complications
IV: Miscellany

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33 Section 2: Trauma
 Table of contents
Frontal Bone Fractures
Lindsey Arviso, M.D.

The frontal bone borders several important structures, most importantly,

the brain. The supraorbital rim and roof of the frontal bone are the superior
boundary of the orbit with the supraorbital and supratrochlear nerves nearby.

I: Common ENT Infections

The frontal bone gives contour to the forehead and encloses the frontal
sinuses completely. Fracture of the anterior wall of the sinus, therefore, may
result in deficits in sinus function or cosmesis. Posterior sinus wall fractures
are more dangerous and may extend into skull base fractures requiring
neurosurgical intervention.

When consulted for a frontal bone fracture, evaluate the forehead for motor
and sensory function. The exit and path of the supraorbital and supratrochlear
nerves could be involved in the defect. Visable or palpable defects or step-offs

II: Trauma
should be noted. Lacerations over non-operative fractures may be closed
under sterile conditions in the emergency room.

A high-resolution axial CT should be performed to evaluate bony defects.

Anterior wall fractures may be present that were not found on physical exam.
Posterior table fractures with any degree of displacement are significant.
Fractures may be described as linear horizontal, linear vertical, comminuted,

III: Operative Complications

and with or without nasal, ethmoid, and lacrimal bone (NOE) involvement.

The bones that provide protection to the orbital contents and anterior fossa
are the thicker bones of the supraorbital rims and frontal bones surrounding
the frontal sinus. In all, for repair of the frontal sinus, alignment of the bones
is all that is really necessary for good healing and outcomes. The most important
topics in regards to frontal fractures are the need for exploration or obliteration.

The anterior table is repaired for aesthetic purposes and to correct sinus outflow
tract disruption. Obstruction of the nasofrontal ducts will lead to chronic sinus
IV: Miscellany

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Section 2: Trauma 34
 Table of contents
infections. Depressed anterior wall fractures may also lead to sinus complications
and should be explored to evaluate mucosal damage, however repair may
be delayed for a period of conservative observation.

I: Common ENT Infections

Posterior wall fractures are more serious in nature. A nondisplaced posterior
table fracture can be observed if the anterior table does not require repair.
With a displaced fracture of the posterior wall, one must consider the involvement
of the dura and the brain. Dura and brain contents may have herniated into
the frontal sinus if the defect is large enough and on the reverse, a frontal
sinus mucocele could encroach and compress the brain. Obliteration eliminates
the frontal sinus. As long as there is no ductal involvement, trephination or
endoscopy are appropriate to exclude herniation of brain into the sinus. If a

II: Trauma
displaced posterior wall fracture is present with no soft tissue defect, sinus
obliteration is performed at some centers.

Outpatient follow up with interval imaging to observe if sinus disease follows

may also be appropriate. Delayed obliteration can be performed if chronic
sinus disease then develops. Comminuted posterior frontal sinus fractures
with intact anterior walls should be obliterated by cranialization to remove the

III: Operative Complications

posterior wall of the sinus and mucosa. This procedure prevents herniation
or mucocele, however, the necessity of this is debated.

CSF leaks from defects in the skull base may occur from traumatic frontal
fractures. These must be identified if possible due to the risk of meningitis.
Skull base defects may be repaired at the time of fracture repair. Skull base
disruption should be addressed early due to its many risks of complications.
A bifrontal craniotomy or transglabellar subcranial approach with collaboration
from neurosurgery allows direct visualization of the anterior fossa for repair.
IV: Miscellany

Crisis guide: Otolaryngology

35 Section 2: Trauma
 Table of contents
Temporal Bone Fractures
Grace Leu, M.D. and Aaron Rogers, M.D.

Lateral skull base fractures are common with serious closed head injury.
These uncommonly present a true correctible emergency but nonetheless
the input of the otolaryngologist is important.

I: Common ENT Infections

Clinical findings may include Battle sign, hemotympanum, TM perforation,
hearing loss, or facial paralysis. CSF otorrhea is also fairly common.

Classically fractures are described as either longitudinal or transverse, relative

to the axis of the petrous ridge; fractures are commonly a combination of the
two types or even comminuted.

Longitudinal fractures are more likely to cause tympanic membrane

II: Trauma
perforation and conductive hearing loss. These are the most common
type of fracture.

Transverse fractures are more likely to injure the facial nerve or cochlea.
These are much less common than longitudinal fractures.
The vast majority of temporal bone traumatic CSF leaks will resolve spontaneously

III: Operative Complications

with bed rest and head elevation. Many clinicians will empirically place the
patient on prophylactic antibiotics for several days as well.

Treatment of the traumatized facial nerve is a controversial issue. Operative

decompression of a paralyzed nerve may be considered, especially in cases
of late-onset paralysis or obvious physical disruption on imaging. Serial seventh
nerve conduction studies are classically described but often may not alter
patient management. Systemic steroid is often advocated.
IV: Miscellany

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Section 2: Trauma 36
 Table of contents
Concerns of hearing loss are usually dealt with in the proceeding weeks
after injury. Typically, patients are assessed with an audiogram after any
hemotympanum has resolved (and after more acute issues are controlled).

I: Common ENT Infections

Surgical exploration with tympanoplasty or ossicular chain reconstruction
may be warranted for persistent conductive hearing loss.

Traumatic TM perforations are usually treated with ototopical antibiotics to

prevent infection (and promote spontaneous closure).

For significant ear canal lacerations an expanding sponge wick (Merocel or

“Pope” pack) may be placed for several days to prevent scar contracture.

II: Trauma
Injury to the carotid canal (and artery) must be ruled out with angiography
if suspected on initial imaging.

III: Operative Complications

IV: Miscellany

Crisis guide: Otolaryngology

37 Section 2: Trauma
 Table of contents
Blunt Laryngeal Trauma
Aaron Rogers, M.D.

Trauma to the anterior neck can pose significant and rapid respiratory
compromise. For this reason, the otolaryngologist is often consulted to
evaluate the stability and patency of the upper airway. Intervention may

I: Common ENT Infections

include an urgent oral intubation or trachestomy, in addition to possible open
repair of the cartilaginous larynx and mucosa.

The biggest challenge in early management is appropriately stratifying the

patients who need a secured airway from those who are safe for observation
alone. These are most often patients who have moderate blunt trauma to the
Zone II neck with only minimal voice or respiratory disturbance.

Blunt laryngeal injuries can result in fracture of the laryngeal cartilages with or

II: Trauma
without dislocation, submucosal or external laryngeal hematoma, mucosal
shearing leading to neck emphysema, upper airway bleeding, or even frank
laryngo-tracheal separation.

The physical exam should start with an assessment of respiratory

distress and voice disturbance. Palpation of the neck for crepitus

III: Operative Complications

(subcutaneous emphysema) or gross cartilaginous disruption is a must.
Some authors argue to be wary of bedside canalization of open wounds as
this could worsen bleeding and pose risk for laryngeal hematoma. Plain-film
X-rays may reveal subcutaneous or mediastinal emphysema. If CT scanning
has been done it is often very helpful, but probably should not be done until
the airway has been evaluated. In general, fiberoptic laryngoscopy should be
your first diagnostic tool (i.e. take it with you to the ED).
IV: Miscellany

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Section 2: Trauma 38
 Table of contents
Smaller soft tissue injuries and nondisplaced fractures with a stable intact
endolarynx can be managed with conservative measures. Patients should
be admitted for 24 hr observation with prophylactic antibiotics and systemic

I: Common ENT Infections

corticosteroids. Larger injuries, disruption of the laryngeal framework, or
dislocated arytenoids may require repair with rigid or wire fixation in
an acute setting once an airway is established. Small injuries may
be approached endoscopically.

Blunt Laryngeal Injury

with clinically stable

Fiberoptic
Laryngoscopy

II: Trauma
Normal Non-displaced cartilage Dislocated
Larynx fracture or mild or comminuted
mucosal disruption fracture or
disrupted mucosa

III: Operative Complications

CT Scan

Minimal edema, Comminuted

non-displaced fracture or
fracture hematoma

Observation Establish Airway,

+steroid Direct Laryngoscopy,
Esophagoscopy,
Plan Repair
IV: Miscellany

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39 Section 2: Trauma
 Table of contents
Penetrating Neck Injury
Shatul Parikh, M.D and Jodi Zuckerman, M.D.

To determine the appropriate management of penetrating trauma to the neck,

it is very important to consider the anatomic location of the injury. Initial
management should consist of basic airway, breathing, and circulation steps of

I: Common ENT Infections

trauma assessment. The airway may be secured with intubation or a surgical
airway. Bleeding should be controlled with pressure and fluid resuscitation.
Cervical spine injury should be assumed and always use C-spine precautions.
Obtaining a brief and accurate history of the mechanism of trauma can be
helpful to provide clues as to where the injury may occur.

In the exam, one must look for signs of neurologic trauma and vascular injury.
Shock, expanding hematoma, evolving stroke, hemoptysis, hematemesis,
profuse bleeding, unequal pulses, and bruits can all be signs of vascular injury.

II: Trauma
Subcutaneous emphysema, stridor, hoarseness, or respiratory distress indicate
tracheal or laryngeal injury. Neck pain, odynophagia, and fever can be signs of
early injury to the esophagus. All penetrating injuries should be managed with
physical exam, airway stabilization, and management of circulation. Obviously
great vessel injury usually mandates early operative exploration.

III: Operative Complications

Zone 1 of the neck: Superiorly bounded by cricoid and inferiorly by sternum
and clavicle. Within this zone lies the subclavian artery and vein, dome of the
pleura, esophagus, great vessels of the neck, recurrent nerve and trachea. In
this zone there may be concomitant thoracic injuries including pneumothorax,
hemopneumothorax, and tension pneumothorax.

In the patient with suspected Zone 1 injury, angiography is indicated to evaluate

the vasculature. Early neck exploration may be considered. Evaluation with
esophagoscopy, contrast swallow exam, and bronchoscopy may also be
considered depending on the extent of injury.
IV: Miscellany

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Section 2: Trauma 40
 Table of contents
Zone 2 of the neck: Superiorly bounded by the angle and inferiorly by the
cricoid. Within this zone lies the larynx, pharynx, base of tongue, carotid
artery, jugular vein, phrenic nerve, vagus nerve, and hypoglossal nerves.

I: Common ENT Infections

In this zone the symptomatic patient should be taken to the OR for neck
exploration. In an asymptomatic patient with penetration of the platysma, due
to the relative ease of exposure and the risk to the carotid artery and jugular
vein, neck exploration is usually advocated prior to other diagnostic entities.

Zone 3 of the neck: Everything between the angle of the mandible to skull
base. Contains the internal and external carotid arteries, vertebral artery,
and cranial nerves I-VIII.

II: Trauma
Angiography is initially performed to assess for great vessel injury. If
exploration is indicated the assistance of a neurosurgeon or vascular
surgeon may be helpful. One may also consider percutaneous
intralumenal procedures to control hemorrhage or psuedoaneurysm
in this risky area. Threading a balloon catheter through the high

III: Operative Complications

neck wound to inflate and control hemorrhage is also reported.

IV: Miscellany

Crisis guide: Otolaryngology

41 Section 2: Trauma
 Table of contents
Section III:

Operative complications

Post -Tonsillectomy Hemorrhage

Clyde Mathison, M.D.

I: Common ENT Infections

Bleeding after tonsillectomy usually occurs either during the first 24 hours (primary)
or greater than 24 hours after surgery (delayed). Delayed hemorrhage is the most
common. Primary post-tonsillectomy hemorrhages are due to surgical technique,
whereas delayed hemorrhages relate to postoperative factors. Generally, a
delayed hemorrhage is attributed to the sloughing of the primary eschar and
usually occurs between postoperative day 5 and day 10.

The blood supply to the tonsil is highly variable and complex but is most commonly
supplied by the ascending pharyngeal and ascending palatine branches of the

II: Trauma
external carotid artery.

When called to the Emergency Department to evaluate a post-tonsillectomy

bleed, it is best to have several pieces of equipment on hand to order assess
and control the bleeding. A head light, tongue depressors, and suction are used
to facilitate better visualization. The proper protective equipment, especially eyewear,

III: Operative Complications

should always be worn. Most authors recommend removing any clot that is present
in order to find where in the tonsillar fossa the bleeding is originating. More often
than not, the bleeding is from either the superior or inferior poles.

IV: Miscellany

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Section 3: Operative complications 42
 Table of contents
I: Common ENT Infections
Several methods have been described in order to stop the bleeding. Having
the patient gargle cold water or suck on an ice cube is a simple method that
occasionally works, and this can be done while you are gathering supplies.
The most tried-and-true methods include cauterization of the fossa using
silver nitrate and holding compression with a gauze or tonsil-sponge soaked
in oxymetazoline, neosynephrine, or epinephrine. Infiltrating the bleeding site
with epinephrine (1:1000) has also been successfully employed. All of these
procedures require complete patient cooperation, which can be very difficult
in children. If these bedside methods fail, then the patient should be taken to

II: Trauma
the operating room for an exploration with cauterization and/or suture ligation
of the offending vessel.

It is the general rule to admit all of these patients for observation to see if the
bleeding resumes. Labs, including a hemoglobin and hematocrit, should be
drawn in order to assess the amount of blood lost. Many patients are nauseated

III: Operative Complications

from the ingested blood and should be placed on appropriate medication.

IV: Miscellany

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43 Section 3: Operative complications
 Table of contents
Carotid Blowout
Ajani Nugent, M.D.

The carotid artery is the main arterial supply of the head and neck. It is a
paired vessel originating on the aortic arch on the left, and the brachiocephalic
artery on the right. Both sides divide into the external and internal carotid

I: Common ENT Infections

arteries at the bifurcation at the superior border of the thyroid cartilage
(approximately C4 level of the spine). The ICA continues on to the skull base
without any branches to the neck. The ECA branches in the neck to provide
flow to the superior thyroid artery, ascending pharyngeal artery, lingual artery,
facial artery, occipital artery, posterior auricular artery, maxillary artery, and
ends as the superficial temporal artery.

The carotid artery is very susceptible to damage from radiation. Carotid

blowout is a term that refers to spontaneous rupture of the carotid arteries

II: Trauma
in patients most commonly preceded by neck irradiation and surgery. There
are three subcategories of the carotid blowout syndrome. In a threatened
carotid blowout, evidence by exam or radiograph demonstrating spontaneous
hemorrhage is inevitable if corrective measures are not taken. In these
cases, there has yet to be any evidence of bleeding. An impending blowout
has already demonstrated self-controlled brisk bleeding known as sentinel

III: Operative Complications

bleeding from a compromised artery. An acute blowout is bleeding that is
refractory to pressure and packing.

Arterial weakening secondary to manipulation during surgery, radical

resection, wound infection, pharyngocutaneous fistula, recurrent
tumor, and disruption to the vaso vasorum from radiation treatment are all
contributors to this devastating complication.
IV: Miscellany

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Section 3: Operative complications 44
 Table of contents
Treatment options are limited. Arterial ligation may control hemorrhage but
also increase risk of cerebrovascular accident. When being called to treat
a potential carotid blowout, one should begin with basic ABC management.

I: Common ENT Infections

Ensure a proper airway, breathing, and circulation with resuscitation
techniques. Manual compression of the neck or intraoral packing should be
performed to increase transmural pressure and decrease bleeding surface area.
Interventional radiology should be notified for the possibility of endovascular
management with embolization. If the source of the bleeding cannot be
identified, an angiogram may be additionally helpful and set the stage for
future embolization. A balloon occlusion may be performed to test collateral
circulation to the brain if the bleeding vessel was emobolized and occluded.
If collaterals are poor, a stent may be placed. Surgical management is

II: Trauma
usually last resort and consists of arterial ligation and would debridement.

III: Operative Complications

IV: Miscellany

Crisis guide: Otolaryngology

45 Section 3: Operative complications
 Table of contents
Tracheostomy Bleeding
Iman Naseri, M.D.

Bleeding from a tracheostomy site may occur within the first 24 to 48 hrs
from the time of the surgery. The causes may stem from multiple factors,
and typically include: requirement for anticoagulation, intrinsic or extrinsic

I: Common ENT Infections

coagulation deficiencies, exposed vessels or bleeding tissues from
the procedure, and improper/excessive postoperative manipulation
of the tracheostomy tube. Several specific operative techniques
combined with various perioperative precautions can reduce such
risks of postoperative bleeding.

General rules that apply to closed surgical wounds do not pertain to a

tracheostomy wound. For example, we cannot place a drain or a wrap-around
pressure dressing for a tracheostomy wound. Nevertheless, a variety of

II: Trauma
materials may be used to prevent potential bleeding foci by way of
tamponade. These materials include a ‘drain’ sponge or a Kerlix-type gauze.
Others include Surgicel or Vaseline strips. All such materials must be carefully
packed inside the wound in the peri-stomal area using a curved clamp. They
should not be placed outside the wound on the skin regardless of how much
pressure it applies. This method would fail to prevent bleeding as it does not

III: Operative Complications

contact the fresh surgical wound. It is important to secure the end of
any strip-type packing with tape to the surrounding skin to ensure that
the packing is seen and properly removed during the postoperative period.

IV: Miscellany

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Section 3: Operative complications 46
 Table of contents
Whether the tracheostomy procedure is performed in the traditional
open versus percutaneously, several principles must be practiced. If
moderate to extensive bleeding is encountered during the tracheostomy,

I: Common ENT Infections

packing of the wound should be performed regardless of the patient’s
presumed bleeding tendency postoperatively. Careful attention must be
given to prevent packing any material inside or close to the lumen of the
trachea. This may potentially lead to aspiration of the packing material into
the distal airway. Encountering anterior jugular vein(s) or thyroid tissue (usually
the isthmus) may potentially increase postoperative risks of bleeding. Careful
identification and control of bleeding from such vessels is crucial, in addition
to proper cauteriziation of any exposed thyroid tissue. Proper tightening of
the tracheostomy tube holder is important in helping with tamponade of

II: Trauma
potential bleeding foci especially when preventive packing is used. A general
rule should be to tighten the strap around the neck enough so that only two
fingers can be placed between the neck and the strap.

Most importantly, vigorous arterial bleeding must be considered a surgical

emergency until proven otherwise. Hemorrhage from the innominate artery,

III: Operative Complications

termed a trachea-innominate fistula, has a mortality rate well over 50%.
About half of such hemorrhages have sentinal bleeds. Management of these
may include an angiogram or operative exploration for diagnosis and operation
with likely sternotomy and innominate artery ligation for treatment. Such dire
cases are fortunately rare but prompt action may be your only chance to
save the patient.
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47 Section 3: Operative complications
 Table of contents
Flap Compromise
Craig R. Villari, M.D.

The development of free-tissue transfer offers the ENT surgeon a valuable

tool in reconstructive surgery. In comparison to a pedicled flap, the free flap
technique requires microvascular anastomosis of the vessels from the donor

I: Common ENT Infections

site to the recipient site. There are multiple ways to check for flap compromise,
but the underlying premise of each technique is the same - flap checks are
aimed at verifying that both arterial and venous flow are present in the
anastomosis. The bulk of flap failures will occur in the first 72 hours of
the post-operative period. Therefore, diligent assessment of flap
viability during that time frame is key to operative success.

When assessing a flap, the first thing a physician should do is to check

the color and quality of the flap. An edematous or boggy flap can indicate

II: Trauma
venous obstruction; conversely, a pale flap can signal arterial compromise.
Capillary refill should also be maintained and evaluated with a free flap. There
are two ancillary techniques that can be used to augment the physical exam.
The first requires the physician to stick the flap with a small-gauge needle
and to examine the color of the resulting bleed. This technique is an indirect
measure of vascular flow; any colored blood other than dark black blood can

III: Operative Complications

indicate good vascular patency.

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Section 3: Operative complications 48
 Table of contents
Obviously, this is a subjective assessment so some surgeons prefer the use
of Doppler technology to assess flow. Doppler signals can be obtained with
implanted leads wrapped delicately around the anastomosed vessels or they

I: Common ENT Infections

can be obtained with hand-held probes placed on the surface of the flap.
Both techniques convert the Doppler reading into auditory signals that can
then be interpreted to evaluate patency of both arterial and venous systems.
Arterial signals are periodic repetitive ‘wooshes’ that coincide with the
patient’s pulse; venous signals are a more constant background noise
comparable to static coming from a television. If either, or both, of these
signals cannot be found, the physician must suspect vascular compromise.

Once vascular compromise has been established, time is of the essence.

II: Trauma
The evidence for the short-term benefits of aspirin or clot-dissolving agents
like streptokinase is limited; surgical exploration of the anastomosis remains
the first-line therapy for flap compromise.

III: Operative Complications

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49 Section 3: Operative complications
 Table of contents
Cervical Hematoma
Candice Colby, M.D.

Post-operative neck hematoma is an airway emergency that can occur

following any surgical procedure where the neck spaces have been violated.
Bleeding can occur following thyroid surgery, neck dissection, or any other

I: Common ENT Infections

operation that violates the neck spaces. The risk is greatest when both sides
of the neck have been operated on, as this will cause the trachea to move in
a posterior fashion and collapse against the spine. Most postoperative
bleeding occurs within a few hours of the operation but sometimes can occur
much later. Commonly the bleed is from a small vessel within or just under
the skin flap. Occasionally cervical hematoma is seen spontaneously in
the absence of surgery, usually due to either a great vessel pseudoaneurysm
or hemorrhagic thyroid or parathyroid adenoma.

II: Trauma
Patients will present with neck swelling or tightness, or with progressive
difficulty breathing. If neck hematoma is suspected, the patient should
be closely monitored for expansion of hematoma and progression of symptoms.
Inspect for tracheal deviation and degree of respiratory distress. Examine the
neck for tense swelling, and whether it is pulsatile or if bruit is present -
suggesting a larger vessel bleed that should be handled in a controlled setting

III: Operative Complications

to ensure patient safety. If present, inspect for surgical drain output (consistency
and amount), bleeding from incision site, or ecchymotic change of the neck.

The determination to re-explore the hematoma is a clinical one, though

threshold for doing so should be low. Airway compromise can occur quickly
and any sign of such compromise should prompt quick action. Be prepared
to explore and decompress the wound locally, in the absence of any anesthesia,
if necessary to control the airway.
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 Table of contents
Whether performed in a dire emergency or in a more controlled fashion,
usually blunt exploration, suction, and profuse irrigation of the surgical bed
will identify the bleeding culprit. Sometimes this is a large identifiable vessel,

I: Common ENT Infections

other times no discrete vessel can be identified. In the latter case the vessel
may have finally thrombosed, retracted into a muscle, or perhaps the the
bleeding was due to a systemic coagulopathy allowing diffuse hemorrhage
from arterioles and venules.

After the wound is irrigated and bleeding controlled, one may consider
applying topical thrombotic agents such as exogenous thombin. Also, consider
that significant supraglottic edema may not be much improved by drainage of
the hematoma, so due caution should be taken upon extubation.

II: Trauma
Preoperative studies may help to predict those at highest risk of bleeding,
but do little in the way of prevention. Similarly placement of a surgical drain
seems to do little to protect the patient from this complication.

III: Operative Complications

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51 Section 3: Operative complications
 Table of contents
Pharyngocutaneous Fistula
Katherine Hayes, M.D.

Pharyngocutaneous fistulas can develop following pharyngeal surgery (i.e.

laryngectomy) as an inappropriate communication between pharyngeal
mucosa and the skin of the neck. Several factors predispose a patient

I: Common ENT Infections

undergoing pharyngeal/laryngeal surgery to fistula formation. Pre-operative
radiation damages tissues at the cellular level via oxidative stress and fibrosis,
thus impeding proper wound healing after surgery. In addition, patients with
malnutrition or systemic diseases such as COPD, diabetes, or CHF also
suffer from poor wound healing and have increased risk of fistula formation
post-operatively. Optimization of nutritional status and management of
underlying chronic disease is critical. From the surgical standpoint, all
efforts should be made to achieve impeccable, tight closure as the most
effective method of preventing fistula formation.

II: Trauma
There are a few signs which should trigger suspicion for fistula formation
including neck edema, erythema, tenderness at suture sites, fever, and
visible drainage. Many advocate a small local wound exploration as part of
the workup of post-operative fever, serving to both identify a leak early and
provide a clear drainage pathway medial to the great vessels. Fistulae most

III: Operative Complications

often develop within the first 7 days, but can be seen up to 6 weeks post-op.
Usually clinical diagnosis will suffice, but barium swallow or methylene blue
testing (visualize dye leaking from wound) can clinch the diagnosis. If a drain
is in place or a sample of fluid can be obtained, elevated amylase confirms
the presence of saliva in the fistula tract.
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 Table of contents
Conservative treatment is first line and includes initiation of tube feeding with
NPO status, addition of clindamycin (or other broad spectrum antibiotic)
if fever or wound erythema is apparent, and packing of the wound with gauze

I: Common ENT Infections

2-3 times per day to facilitate wound healing and prevent further damage to
surrounding skin and soft tissue. Placement of a temporary drain may be
helpful to prevent seepage into a nearby stoma and avoid aspiration.
Additionally, salivary diversion tubes may be placed in the pharynx in an
attempt to reduce exposure of the wound to saliva.

One should be concerned if a lateral fistula has developed due to the

possibility of soft carotid artery adventitial breakdown. Due to the risk of
carotid blowout in this situation, further imaging with CT and closure with a

II: Trauma
local myocutaneous or pectoralis major flap is likely the best option. If
conservative treatment for 2-3 weeks shows no signs of fistula closure,
surgical closure becomes necessary. Primary closure is feasible in patients
with adequate non-necrotic mucosa which can be approximated with minimal
tension (this is uncommon). Other patients require secondary closure with
regional muscle or fasciocutaneous flaps.

III: Operative Complications

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53 Section 3: Operative complications
 Table of contents
Hypocalcemia
G. Aaron Rogers, M.D.

Hypoparathyroidism after thryoidectomy is the most common cause of acute

hypocalcemia seen by the otolaryngologist. The etiology is usually inadvertent
removal or devascularization of the parathyroid glands following total, or completion,

I: Common ENT Infections

thyroidectomy. Theoretically, any neck surgery can have this complication.

Calcium circulates in blood as a cation, largely sequestered by albumin and

other proteins. Free ionic calcium is the “active” form, however is difficult and
expensive to measure directly. Total serum calcium is measured most
commonly, and includes calcium bound to albumin. A simple formula is
used to correct calcium levels in states of hypoalbuminemia:

Corrected Ca = Measured Ca + 0.8 x (4 - Albumin)

II: Trauma
Additionally, states of hypomagnesemia will cause renal
sacrifice of calcium to spare magnesium, making hypocalcemia even more
difficult to treat.

Signs and symptoms of hypocalcemia in this setting are usually isolated to

III: Operative Complications

muscular complaints, tetany, and cardiac arrthymias. Generalized seizures
and laryngospasm are also possible. Subacute mild hypocalcemia may also
present with psychosis.

Chvostek’s sign is a facial muscle spasm elicited by firmly

tapping the parotid gland (proximal facial nerve). Trousseau’s sign is carpopedal
spasm seen after momentary ischemia to the forearm (as with a
blood pressure cuff). EKG changes include a lengthening of the QT interval
(and corrected QT interval), and a lengthening of the ST interval. T-wave
changes may be seen as well. Heart block and ischemia may result.
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 Table of contents
There are various algorhythms for managing postoperative calcium
replacement. After total thyroidectomy we routinely check serum
calcium, albumin, and magnesium every 8-12 hours for 24 hours.

I: Common ENT Infections

Calcium replacement of the asymptomatic patient usually begins when
the corrected calcium is less than 8.4mg/dL. We typically replace with
oral Calcium Carbonate + Vitamin D (OsCal D(r)) 500-1000mg TID. For
calcium levels below 7mg/dL, replacement with IV calcium gluconcate
1-2g is appropriate.

For symptomatic patients (especially with EKG changes) IV calcium replacement

is preferred. Adults who require multiple IV boluses may benefit from a calcium

II: Trauma
gluconate maintenance “drip” of 100mg/hr for 24 hours. Keep in mind that these
patients will still benefit from the relative speed of preparation and administration of
oral calcium; some physicians keep Tums® at the bedside.

When replacing with oral calcium remember that an acidic gastric

environment is required for absorption, so tablets should be given with meals.

III: Operative Complications

Absorption will be unpredictable if the patient is on antacid medications.

When treating any patient for hypocalcemia, remember that the most
common serious complication is heart block and arrhythmia. Some patients
may require multiple EKG’s or constant cardiac monitoring.

Medicine or endocrinology consults also may be helpful.

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55 Section 3: Operative complications
 Table of contents
Cerebrospinal Fluid Leaks
Eric Berg, M.D.

Cerebrospinal fluid leaks may be caused by iatrongenic injury, trauma, or

spontaneous occurance. Such a leak may be diagnosed immediately or
may have a more delayed presentation. Leaks may also be seen with

I: Common ENT Infections

congenital anomalies, skull base neoplasms, or erosive processes. If
no identifiable cause is found, the leak may be termed idiopathic.

Patients typically present with complaints of clear, salty, watery nasal drainage
from the nose or ears made worse when the head is lowered or with valsalva
or strong coughing (all of which increase ICP). Defects involving the cribriform
plate may present with disturbance of smell. It should be noted that CSF
otorrhea may present as rhinorrhea via collection in the middle ear and drainage
via the eustachian system.

II: Trauma
Evaluation is basically a two step process; first one must confirm that the
fluid is in fact CSF, then one must localize the defect(s). Fluid should be
collected for analysis. The “halo sign” is non-specific and refers to fluid
separation on gauze with an external fluid ring and a central spot of blood.
A glucose level greater than 30 mg/cc suggests CSF but has a high

III: Operative Complications

false-positive rate and may be falsely-negative in the presence of active
bacterial meningitis. The most specific test is an assay for β2-transferrin.

Once CSF has been confirmed, evaluation is generally followed by a

high-resolution CT scan for bony evaluation. MRI to evaluate soft tissue
is complementary. Interthecal radioactive dyes or fluorescein may be
employed using cotton pledgets as a more sensitive but non-localizing
test. Endoscopic evaluation may directly visualize a leak or even
prolapsing cranial contents.
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 Table of contents
In the case of accidental trauma, management is initially conservative with
bed rest, elevation of the head of bed, avoidance of strain, stool softeners,
and osmotic and diuretic agents. Prophylactic antibiotics are controversial

I: Common ENT Infections

but empiric therapy is imperative if meningitis is suspected. If no improvement
is seen after 2-3 days of conservative management, lumbar drain placement for
CSF diversion or definitive surgical management should be considered. If a leak
is a recognized surgical complication, repair should be attempted immediately.

Nontraumatic leaks and leaks of an extended

duration are more likely to require surgical
repair. Modern operative approaches
are primarily endoscopic. Basic principles

II: Trauma
consist of selection and possible harvest of
graft material, graft application, and graft
stabilization. Post-repair management
includes observation in an ICU with lumbar
drain management for ~5 days in addition
to the conservative measures outlined

III: Operative Complications

above. Strenuous activity should be
avoided for approximately 6 weeks.

Inappropriate or delayed management of cerebrospinal fluid leaks may

have devastating complications. Skull base defects leave patients
vulnerable to meningitis, cerebral abscess, pneumocephalus,
intracranial hemorrhage, and secondary cerebral compression.
Prompt evaluation and management is essential.
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57 Section 3: Operative complications
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Orbital Hematoma
Kara Prickett, M.D.

Orbital (or retrobulbar) hematoma is a rare but serious complication of trauma

to the orbit or surgical intervention in or around the orbit. Due to the relative
inelasticity of the periorbita and its firm fixation to the orbital rim, collection of

I: Common ENT Infections

blood within the orbital space can result in a rapid rise in pressure and
development of orbital compartment syndrome. As pressures rise, they
may reach levels sufficient to cause external compression of retinal veins
and arteries. Resultant retinal ischemia can lead to permanent blindness
in as little as 60-90 minutes.

The diagnosis of orbital hematoma is primarily clinical, and index of suspicion

should rise if there is a plausible mechanism in the history. Almost all cases
are preceded by surgery or trauma; symptoms may progress rapidly, or over

II: Trauma
several days, depending on the source of the bleed. Signs and symptoms
suggestive of orbital hematoma include proptosis, chemosis, eye pain,
progressive decrease in visual acuity, and opthalmoplegia. Fundoscopic
examination may show papilledema and a pale optic disc, but is not
always feasible in the emergency setting. Documentation of increased
intraocular pressure is important to establish the diagnosis, with most

III: Operative Complications

reported cases having IOP > 40 mmHg (normal IOP 10-20 mmHg).
Lab or imaging studies may delay sight-saving treatment and are not
usually indicated.

The differential diagnosis includes retrobulbar edema (the most likely cause of
proptosis in trauma patients), sub-periosteal hematoma, orbital emphysema,
anterior ischemic optic neuropathy, central retinal artery occlusion, and
traumatic injury to the globe.
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Management should begin with standard ATLS protocol to assess for
life-threatening injuries in any trauma patient. Urgent ophthalmologic
consultation is always indicated. In rapidly progressive cases, immediate

I: Common ENT Infections

initiation of pharmacotherapy with osmotic agents and/or carbonic
anhydrase inhibitors and orbital decompression via lateral canthotomy
should be undertaken. Reassessment of intraocular pressure and
visual acuity after orbital decompression is important; if acuity does not
improve and pressures do not fall significantly, other diagnoses such as
orbital emphysema or sub-periosteal hematoma should be considered. The
patient should be admitted for serial examinations and monitoring. Cosmetic
repair of the lateral canthus may be undertaken prior to discharge or at a later
date with good result.

II: Trauma
Performing a lateral canthotomy
Lateral canthotomy can be safely performed with the contents of a
basic instrument tray. Lidocaine 1-2% with or without epinephrine
should be infiltrated into the area of the lateral canthus. A small clamp
can then be placed with one tine inside the lid and one tine outside the lid

III: Operative Complications

and directed toward the lateral orbital wall where the attachment of the lateral
canthal tendon should be palpable. The clamp is tightened for 60 seconds
to provide a guide for incision and to prevent undue bleeding. Incision of the
skin and removal of the tendon from its insertion on the orbital rim may be
done with a scalpel or (more safely) with small, sharp scissors. The plane
of orbital septum and canthal tendon MUST be violated to provide
adequate decompression.
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59 Section 3: Operative complications
 Table of contents
Section IV:

Miscellany

Epistaxis
Lindsey Arviso, M.D.

I: Common ENT Infections

Nosebleed is one of the most common conditions an otolaryngologist will
be asked to evaluate. Usually from the anterior septum, 90% are located at
Kiesselbach’s plexus in Little’s area, a confluence of vessels at the anterior
septum. Injury or anything that produces hyperemia in the nasal mucosa
predisposes to epistaxis, including: trauma, digital manipulation, vigorous
blowing, sinusitis, allergy, neoplasm, hypertension, renal disease, hepatic
failure, hemophilia, acquired thrombocytopenia, hereditary hemorrhagic
telangiectasia, blood thinners, NSAIDs, thioridazine, dipyridamole,
anticholinergics, nasal sprays, decongestants, and cocaine.

II: Trauma
A significant nosebleed may require urgent attention and management. Similar to
a trauma situation, large-bore peripheral IV access is a must. Face mask, gown,
and gloves for the provider are pertinent. Take a history regarding inciting factors,
therapies already attempted, and approximate blood loss.

III: Operative Complications

First line treatment of epistaxis should include a trial of direct pressure applied for
15 minutes. Topical neosynephrine, epinephrine, or oxymetazoline applied liberally
to the nasal mucosa are also very useful. Any contributing medical factors should
be optimized if possible.

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I: Common ENT Infections
Cautery with silver nitrate may be attempted for small anterior bleeding
vessels. Packing with an expanding nasal tampon or inflatable compression
balloon pack is usually definitive but painful. Moderate bleeding from the
posterior nasopharynx is often controlled by longer (10cm) nasal tampons
or a double-balloon style pack (Epistat).
Tamponade of the nasopharynx can also be achieved via a Foley catheter
balloon or posterior gauze packing. Failure of the above interventions may
require percutaneous intralumenal embolization Epistaxis or surgical ligation.

II: Trauma
Anterior Packing
with Nasal Tampon

III: Operative Complications

Posterior Packing
with Gauze Roll

Posterior Packing
with Foley Catheter
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61 Section 4: Miscellany
 Table of contents
Angioedema
Jodi Zuckerman, M.D.

Angioedema is caused by post capillary venule inflammation that results in

leakage and edema in the submucosal and subcutaneous layers. This is
triggered by inflammatory mediators such as histamine, serotonin, and kinins.

I: Common ENT Infections

This can occur in the face, lips, floor of mouth, tongue, pharynx, and larynx.

The causes of angioedema are numerous and can be classified as IgE

mediated, complement mediated, hereditary, idiopathic, and drug reaction
(most commonly ACE inhibitors).

The on-call otolaryngologist needs the following items to be truly equipped

in the work up of the patient with angioedema: tongue blade, light
source, topical vasoconstricting and anesthetic agents, flexible

II: Trauma
laryngoscope, intubation supplies including (endotracheal tube and
anesthetic agents), and lastly a tracheostomy tray.

The work up should begin with obtaining a history to provide details to the
allergen or trigger. A physical exam should detail the oropharynx specifically
determining tongue swelling and visualization of the posterior tonsillar fossa.

III: Operative Complications

Flexible laryngoscopy can then be performed to determine if swelling extends
to the pharynx and larynx. Imaging is not indicated in this setting.

Definitive treatment is of course medical in nature, however stabilization of the

airway may be required while awaiting resolution of symptoms. The decision
on whether to establish an airway should be based on the overall clinical
presentation, not a single exam finding. Most important is the patient’s
progression of symptoms over time.
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Vital signs,
Cardiopulmonary
monitoring

I: Common ENT Infections

Medical Rx: If known
IV steroid, IV H1/H2 Hereditary
blockade, Nebulized Angioedema,
epinephrine & steroid, give FFP or
humidified oxygen C1-Inhibitor protein

Stridor or Oropharyngeal Exam,

air-hunger? Yes Flexible Laryngoscopy

II: Trauma
No

Limited to lips, Supraglottic

tongue, oral mucosa, or Glottic
with visualized edema with
tonsillar pillars stridor

III: Operative Complications

Observation in Establish urgent
monitored setting (ICU, airway via
ER) untilmarked Worse attempting awake
turnaround in nasotracheal intubation
symptoms vs tracheostomy
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63 Section 4: Miscellany
 Table of contents
Inhalation Injuries
Elizabeth Hoddeson, M.D.

Inhalation injuries can result from inhalation of noxious substances or from a

fire, particularly in an enclosed space, with injury resulting from inhalation of
smoke, hot dry gas, or steam. With hot dry gas, injuries are often limited

I: Common ENT Infections

to the oropharyngeal and upper airway due to the dissipation of heat in the
nasopharyngeal and oropharyngeal tissues and glottic adduction reflex to
heat to protect the lower airways. The heat capacity of steam is much
greater than that of dry air, and the upper airways are often overwhelmed by
the insult, resulting in a higher frequency of injury to the lower airway tissues.
The mucosa of the respiratory tract is highly specialized in order to properly
serve its important functions of humidification and prevention of small substrates
from reaching and occluding the very small spaces of the lower airways. The
lungs are highly susceptible to injury and cell death from exposure. Airways are

II: Trauma
left vulnerable to accumulation of mucus and substrates in lower airways that
may form obstructive plugs and serve as a medium for bacterial growth.

Upon examination of a patient with suspicion for inhalation injury, signs that
prompt concern include facial burns, singed facial and nasal hair, carbonaceous
sputum, wheezing, stridor, cough, oropharyngeal edema, tachypnea,

III: Operative Complications

respiratory distress, copious sputum production, and thick secretions.
Symptoms often evolve and can be delayed in situations of inhalation injury
up to 24 – 36 hours. The best tests to detect inhalation injuries include direct
fiberoptic laryngoscopy and bronchoscopy.

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Conservative management of suspected inhalation injury may be initiated as
the patient is closely monitored in order to detect possibly evolving symptoms;
this includes cool humidified oxygen and systemic rehydration. Use of

I: Common ENT Infections

steroids in this setting is not supported in the literature. Definitive management
of inhalation injury is securing the airway through early endotracheal
intubation prior to development of an emergent airway situation. This allows
for suctioning of lower airways and prevention of upper airway occlusion as
edema progresses. Tracheotomy may be required either emergently, in
situations of significant injury to the larynx in order to avoid further trauma by
forced orotracheal intubation, or established as a secondary measure if
ventilation dependency ensues or for very thick secretions difficult to manage
through an endotracheal tube. Tracheotomy should be weighed carefully in

II: Trauma
the setting of significant burn to the neck, which will adversely affect wound
healing and serve as a nidus for infection.

Pneumonia and tracheobronchitis are common complication in patients

with inhalation injury due to decreased ciliary function for mucus and soot
clearance and increased permeability of alveolar membranes resulting in

III: Operative Complications

lower airway flooding.

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65 Section 4: Miscellany
 Table of contents
Facial Nerve Paralysis
Craig R. Villari, M.D.

The course of the facial nerve can be grossly characterized into three subdivisions:
intra-cranial, intra-temporal, and extra-cranial. Paralysis can result from several
mechanisms including congenital, traumatic, infectious, neoplastic, iatrogenic,

I: Common ENT Infections

and idiopathic processes. As with building a differential diagnosis for other
conditions, the provider should obtain information about the onset, characteristic,
contributing factors, and associated symptoms involved in the paralysis.
The House-Brackmann grading system (below) is useful in communicating
the degree of paralysis to other providers.

House-Brackmann Class Key Characteristics

Grade I - Full function
Grade II - Slight weakness

II: Trauma
Grade III - Slight, but appreciable weakness; can still close eye
Grade IV - Incomplete eye closure but symmetrical facial muscular tone at rest
Grade V - Obvious disfigurement but retains some muscular function
Grade VI - No function

The facial nerve is susceptible to severe trauma resulting in transverse

fractures of the temporal bone. Fortunately, for facial nerve function,

III: Operative Complications

those fractures are less common than longitudinal fractures. Treatment
options for temporal bone fractures affecting the facial nerve include
steroids and surgical decompression.

The more distal branches of the facial nerve are also vulnerable even with
fairly superficial lacerations. After copious irrigation to cleanse the wound,
early surgical neurroraphy using either primary or cable graft technique
should be considered.
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There are many causes of infectious facial nerve paralysis, but the most
well studied are Ramsay Hunt Syndrome and Lyme disease. Ramsay Hunt
syndrome results from the reactivation of latent herpes simplex virus. It is

I: Common ENT Infections

almost exclusively unilateral in presentation and is easily diagnosed when
telltale painful vesicles are also present. Treatment requires a 7-10 day
course of acyclovir and steroids. Ophthalmology should be consulted if
eye involvement exists.

Lyme disease is caused by a spirochete transmitted in the bite of the Ixodes

tick. The disease can present with unilateral or bilateral paralysis and is
most-easily diagnosed when the classic ‘bull’s eye’ rash is present.
Treatment is focused on appropriate antibiotic treatment, usually

II: Trauma
doxycycline or cefuroxime.

Bell’s palsy is the most common cause of facial paralysis. It is an idiopathic

disorder of acute onset that is almost always unilateral. A stroke workup is
necessary if there is sparing of forehead movement. Though the exact
etiology of the disorder is unclear, it is usually treated with a 10 day
course of steroids; of note, treatment does not alter disease prognosis if

III: Operative Complications

initiated 3-4 days after onset. Surgical decompression of the facial nerve
may be considered when refractory to medical treatment or recurrent in nature.

It is important to remember several principles when treating a patient with

facial nerve paralysis. Patients are sometimes seen by a neurologist before
coming to an otolaryngologist’s attention, but a full neurologic exam should
be performed to rule-out other neurologic deficits. Additionally, one cannot
underemphasize the importance of ophthalmologic care if there is any inability
to protect the eye; depending on the degree of paralysis, simple eye
lubrication or tarsorrhaphy may be indicated.
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67 Section 4: Miscellany
 Table of contents
Sudden Sensorineural Hearing Loss
Praveen Duggal, M.D.

Sudden Sensorineural Hearing Loss (SSHL) is defined as a sensorineural

hearing loss of greater than 30dB over three contiguous pure-tone frequencies
occurring within a 3-day period. Sudden loss can occur from many causes

I: Common ENT Infections

such as infection, autoimmune disease (Sarcoid/Wegeners granulomatosis
/Cogan syndrome), vascular compromise, retrocochlear pathology/tumor,
trauma to the temporal bone, pharmacologic toxicity, or idiopathic. Most
SSHL are idiopathic and include both abrupt and rapidly progressive losses
without an explained cause or underlying pathology. Incidence of 5-20
per 100,000 persons a year. Average age ranges from 40-50’s with equal
sex distribution. SSHL is most likely a symptom that may have several
different known and/or unknown etiologies. Four different pathways have
been discussed as possible idiopathic SSHL causes including

II: Trauma
• Viral infection
• Vascular compromise
• Intracochlear membrane rupture (double membrane break theory)
• Autoimmune mediated

III: Operative Complications

One fourth of all SSHL patients report a viral infection within 1 month of their
loss. SSHL has been shown to possibly be linked with damage by active or
latent viruses to cause loss of hair cells or other inner ear structures. Inner
ear vascular compromise from occlusion or obstruction may lead to reduction
in cochlear blood supply. Rupture of any of the membranes separating the
perilymph and endolymph may lead to a change in the membrane potentials
needed for hearing. Autoimmune causes can be associated with other
immune mediated disorders but remains unclear in SSHL.
IV: Miscellany

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Section 4: Miscellany 68
 Table of contents
Evaluation should include time onset and course of SSHL, symptoms associated
with loss, and what occurred before/during/and after loss. Medications
should be reviewed for any ototoxic side effects. A complete head and neck

I: Common ENT Infections

physical exam should be performed with thorough evaluation of the ears, as
well as a thorough neurologic/cranial nerve evaluation. The Hum, Weber, and
Rinne tests may be of use to determine side of loss and SSHL vs conductive
hearing loss.

Labs should include an ANA, RF, and ESR to rule out autoimmune
causes. A WBC as well as FTA-Abs can be ordered to rule out infection
and possible syphilis.

II: Trauma
Audiometry is a mandatory test that needs to assess baseline hearing and/or
loss. ABR and OAE can be ordered to assess auditory nerve and cochlear
function. An MRI with gadolinium is excellent for evaluating retrocochlear
masses. Most agree this need not be done in an inpatient setting.

Treatment for SSHL should consist of treating the underlying etiology.

III: Operative Complications

Current empiric standard of care for idiopathic SSHL is a tapered course of
oral corticosteroids. Prednisone 60mg over 4 days followed by a taper of
10mg every 2 days over 10-14 days is adequate. Greatest recovery is
noted when steroids are initiated within the first 1-2 weeks of symptom onset.
Little benefit noted after 4 weeks. Antiviral agents have mixed results, and if
used should be given in combination with steroids. Intratympanic steroid
injection has been effective in patients with severe/profound SSHL that have
failed standard treatment. Carbogen is an inhalational vasodilator that
can improve cochlear blood flow and help with sudden deafness, though
it is rarely used.
IV: Miscellany

Crisis guide: Otolaryngology

69 Section 4: Miscellany
 Table of contents
Foreign Bodies
Avani Ingley, M.D.

Esophageal Foreign Bodies

Foreign body ingestion is a common problem in both adults and children. In adults,
the most likely objects are fish bones, dentures, and meat. Children are most likely to

I: Common ENT Infections

swallow coins. Ninety-five percent of esophageal foreign bodies become lodged at the
cricopharyngeus; other common locations are the gastroesophageal junction, and the
indentations of the aortic arch and left mainstem bronchus.

Patients typically present with dysphagia, drooling, weight loss, chest pain, or fever.
The first step in evaluation is a chest X-ray. It is key to get a lateral x-ray in children
who have swallowed coins to confirm the number of coins in the esophagus. If X-rays
do not reveal a foreign body and the patient has a convincing history and physical
exam, then exam under anesthesia with either flexible or rigid esophagoscopy should

II: Trauma
be pursued. Barium swallow should be avoided as it may obscure the endoscopic view.
Patients who are drooling or in any respiratory distress should be taken to the
operating room urgently. Asymptomatic patients should be taken to the operating
room within 24 hours. Patients with disc batteries should have them removed urgently.

Complications include esophageal perforation, aspiration, mediastinitis,

pneumothorax, and pneumomediastinum.

III: Operative Complications

Airway Foreign Body
Airway foreign bodies present a diagnostic and therapeutic challenge to the
otolaryngologist. Typically, the patients present to the emergency department
or primary care physician. Physicians should have a high index of suspicious
for aspiration, especially in children because foreign body aspiration can mimic
many other conditions. The most commonly aspirated objects are peanuts,
balloons, hot dogs, or small toys. History from witnesses can be a key
element in diagnosis.
IV: Miscellany

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Section 4: Miscellany 70
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Patients can present with choking, stridor, chest pain, hoarseness, or wheezing.
A chest x-ray with inspiratory and expiratory phases should be performed to evaluate
for radiopaque items and for air trapping. Objects can become lodged anywhere along
the airway, but the most common are at the level of the larynx, in the trachea, or the

I: Common ENT Infections

right mainstem bronchus.

Management involves laryngoscopy and rigid bronchoscopy. Light sedation with short-
acting muscle relaxants and jet ventilation should be used. Intraoperative with or
without post-operative steroid should be given to reduce inflammation. If removal is
not accomplished with rigid bronchoscopy, then a thoracotomy may be necessary.
ALWAYS LOOK FOR A SECOND OBJECT

Complications can include pneumonia, pneumothorax, pneumonitis, parenchymal

loss, or chronic lung infections.

II: Trauma
Nasal Foreign Body
Nasal foreign bodies should be removed with little delay as there is a potential
for aspiration or airway obstruction. Instruments necessary include nasal
speculum, nasal suction, small ear instruments with curvature such as (mastoid
pick and wax curette), and foley catheters. With assistance from ancillary staff,

III: Operative Complications

the patient can be papoosed in place. After anesthetizing, the nose instruments
can be used to grab the foreign object and remove it.

Ear Foreign Body

Most critical in this assessment is to determine what exactly the foreign body
is. If it is a food particle or bean it may expand with irrigation and become
extremely painful for the patient. If a report of a battery or a caustic substance
is lodged in the ear, this must be removed immediately to avoid corrosive damage
to surrounding structures. Otherwise, it is common practice to remove these
foreign bodies under microscopy in clinic as an outpatient.
IV: Miscellany

Crisis guide: Otolaryngology

71 Section 4: Miscellany
 Table of contents
Tracheostomy Care
Anita Sethna, M.D.

Triaging tracheostomy problems is one of the most common issues that

may arise on call. Common complications after tracheostomy and
initial management strategies are listed below.

I: Common ENT Infections

Bleeding: a separate chapter addresses tracheostomy bleeding.
Consider packing with hemostatic gauze if not severe.

Pneumothorax: Occurs in up to 4% postoperatively. A chest xray is

diagnostic. A small pneumothorax can sometimes be managed with
high-flow oxygen (and avoiding positive pressure ventilation). Otherwise,
a chest tube will be required.

II: Trauma
Post-obstructive Pulmonary Edema: Due to acute relief of airway
obstruction, the alveoli can become flooded with interstitial fluid
(and even luminal fluid). CXR and clinical suspicion is diagnostic.
Diuresis or positive pressure ventilation may be required.

III: Operative Complications

IV: Miscellany

Crisis guide: Otolaryngology

Section 4: Miscellany 72
 Table of contents
Tracheitis: Some degree of tracheitis will always be present in trach patients.
Minimizing irritation is possible by tracheal humidification, even by “aspirating”
and coughing up sterile saline (often in 1-3mL bullets). Also, ensuring a firm

I: Common ENT Infections

trach holding strap will help prevent the tracheostomy tube from irritating the
tracheal walls.

Mucous Plugging: If this is suspected, remove the inner canula, and replace
or clean it. If the plug is distal in the airway then aggressive suctioning or even
bronchoscopy may be necessary. Regular irrigation and humidification will
help minimize this.

Tracheostomy Tubes: A size 6 Shiley tube will be large enough for most

II: Trauma
patients. Unless a patient requires positive pressure ventilation, a cuffless tube
is usually best. Some may advocate a cuffed tracheostomy tube for aspirating
or bleeding patients as well.

III: Operative Complications

IV: Miscellany

Crisis guide: Otolaryngology

73 Section 4: Miscellany
 Table of contents
Ventilating Bronchoscope

Legend: Ventilating Bronchoscope Setup

A. Rigid Bronchoscope, bevel up with light port inferior, ventilator circuit

I: Common ENT Infections

port superior, visualization port left and accessory suction/irrigation port.
B. Ventilator circuit and port.
C. Prism adapter for light cord. Needed for visualization when not using a telescope,
and still needed for creating a seal when illuminated telescope is used.
D. Accessory port cover and plug. Needed for seal.
E. Eyepiece or lens. Needed for seal when not using a telescope.
Connects directly to bronch scope without using the bridge.
F. Bridge. Held by friction onto bronch scope and has locking mechanism
to attach to telescope.

II: Trauma
G. Telescope, locked to bridge with bridge pushed firmly onto bronch scope.

The bottom image demonstrates the assembled bronchoscope /

telescope most commonly used. A camera and light cord are yet
to be attached to the telescope. The bronchoscope is carefully
slid through the larynx after direct laryngoscopy using a Parsons

III: Operative Complications

or similar open-ported rigid laryngoscope.

IV: Miscellany

Crisis guide: Otolaryngology

Section 4: Miscellany 74
Table of contents I: Common ENT Infections II: Trauma III: Operative Complications IV: Miscellany

Crisis guide: Otolaryngology

Section 4: Miscellany
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C
B
D

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