ENT, Maxillofacial and Dental Emergencies

Basic Examination

• Appropriate equipment including adequate illumination and suction is required.
• Topical vasoconstrictors and anesthetics facilitate examination. The medication is applied to a cotton pledget, inserted into the naris and left in place for 5-10 min. An alternative is insufflation of aerosolized medication.

• The vascular system of the nasal structures has multiple sources including terminal branches of the internal and external carotid arteries.
• Kiesselbach's plexus is a rich venous network located at the anterior septum and is the source of bleeding in the majority of cases.

• Children and persons exposed to cold, dry air conditions are often affected. Minor nasal trauma is a common cause, but the possible etiologies are numerous.
• Hypertension contributes to the severity and duration of bleeding. However, there is no clear evidence to support elevated blood pressure as a primary etiology.

• Remove existing blood clots prior to examination and pretreat the patient with local anesthetics and/or vasoconstrictors (see "Basic Examination").
• Determine whether bleeding is anterior or posterior, which chamber in involved and localize the exact site if possible. More than 90% of cases are anterior. In general, posterior bleeding is very brisk and difficult to control. These patients may also have hemodynamic instability, bilateral nares involvement, isolated oropharyngeal bleeding and continued bleeding after placement of adequate anterior packing.
• If the patient has severe bleeding, hemodynamic instability or significant underlying disease or risk factors such as coagulopathy, appropriate laboratories should be obtained.

4% Lidocaine (A)
4% Cocaine (V/A)
0.5% Phenylephrine (V)
Epinephrine 1:1000 (V)

Etiology of epistaxis

Idiopathic
Iatrogenic	Surgical procedures, nasal foreign body removal, nasogastric/ nasotracheal tubes
Trauma	Nose-picking, fractures, foreign bodies
Local irritants	Cocaine, nasal sprays, cigarette smoke, toxic gases
Inflammatory	Rhinitis, sinusitis, granulomatous disease
Mass lesions	Nasal/sinus tumors, carotid artery aneurysm
Medications	Anti-platelet agents, NSAID’s, warfarin, heparin
Systemic disease	Liver/renal failure, DIC, thrombocytopenia
Congenital	Hemophilia, von Willebrand disease, Rendu-Osler-Weber disease, sickle cell disease

NSAID: Non-steroidal anti-inflammatory drug
DIC: Disseminated intravascular coagulation

Treatment
Many methods exist. In addition, attention to any premorbid conditions and/or hemodynamic instability is mandatory.

• Direct pressure: Manual pressure applied to both nasal alae in a pinching fashion for 10-15 min is often effective and should be used during prehospital care and during preparation for more definitive treatment.
• Cautery:An excellent method of treatment when an obvious site of bleeding is identified.
  • Both silver nitrate applicator sticks and electric devices are available. Silver nitrate cautery is usually ineffective in cases of profuse bleeding.
  • Risks include increased bleeding and septal perforation. These risks are minimized by use of silver nitrate vs. electrical. Avoid use of cautery on both sides of the septum and do not apply for more than 5-10 seconds. Use with caution in pediatric patients.
• Nasal packs: Placement of nasal packs is very effective in controlling epistaxis especially when the bleeding site cannot be adequately visualized or is not accessible to cautery. Unfortunately, packing is uncomfortable, unaesthetics and carries risks of both sinusitis and toxic shock syndrome. When placing nasal packs, take care not to over-distend the cavity or alae as this may lead to pressure necrosis. Numerous materials are available.
  • Gauze strips: Either petrolatum or iodoform gauze is appropriate. The gauze is layered using bayonet forceps from the posterior base of the nasal cavity upward and outward. Covering the gauze with bacitracin antibiotic ointment prior to placement is recommended to decrease risk of toxic shock syndrome.
  • Expandable sponges/cotton pledgets: This includes Merocel and the popular Rhinorocket. Lubricate with antibiotic ointment prior to placement. Once in place, adequate expansion is achieved via injection of 3-10 ml of saline or otic antibiotic, otic emergencies solution into the body of the sponge.
  • Absorbable hemostatic material: Includes Gelfoam sponges and Surgicel. These may be used as packs and also work by forming a clot upon contact with the bleeding site. Ideal for patients with coagulopathy because they don’t require removal.
  • Posterior packs: For posterior bleeding, balloons (see below) provide more rapid control. If balloons are not available, a posterior pack can be made by rolling several 4 x 4 gauze pads and securing with suture material. They are placed in a retrograde fashion by using a nasally inserted Foley catheter as a guide. Posterior packing is also achieved by placement of a Foley catheter through the naris followed by slow balloon inflation with 10-15 ml of saline once the catheter tip is in the nasopharynx.
  • Epistaxis balloons: These are easier to place and better tolerated than conventional packing. Once in place, the balloons are inflated with enough water to control bleeding. Inflation should not exceed the maximum volume specified on the device. The posterior balloon is inflated first. If only anterior control is needed, the posterior balloon remains empty.
  • Other: Cautery and packing sometimes fail to control severe bleeding especially if posterior. In these cases, emergent ENT consultation should be obtained. Endoscopic cautery, arterial ligation and arterial embolization are other therapeutic options.

• Patients with packing or balloons are at risk for developing sinusitis secondary to occlusion of the sinus ostia so appropriate antibiotic coverage is warranted. Analgesics are also recommended. Packs and balloons are left in place for 2-5 days prior to removal.
• Instruct patients to avoid straining, nose blowing, alcohol intake and use of antiplatelet medications. Appropriate follow-up should be arranged.
• Admission for continuous pulse oximetry and supplemental oxygen is recommended for patients with posterior packs or balloons. In addition, consider admission for patients with anterior packs if they are elderly or have underlying cardiovascular disease.

Risk Factors

• Nasal foreign bodies (FBs) are seen most commonly in children.
• Others at risk include psychiatric patients and people with nasal piercings.

• A detailed history is often available by the caretaker who witnessed placement of the FB.
• Symptoms include unilateral nasal discharge, difficult nasal respiration and epistaxis.
• Purulent drainage and sinusitis are seen with FBs that have been present for an extended period of time. A complete head and neck exam is indicated to rule out additional FBs.
• The object is often visible on physical exam. Nasal radiographs are useful for radiopaque FBs. Order soft tissue neck and chest films if aspiration is suspected.
• Differential diagnosis includes nasal polyps, nasal tumors, unilateral choanal atresia and sinusitis.

• Have cooperative patients try forceful nasal exhalation with manual occlusion of the uninvolved naris.
• Depending upon the shape and size, FBs are removed with a small suction catheter, ear loop or alligator forceps. Alternatives include cyanoacrylate glue applied to the tip of a wooden applicator or Fogarty catheter placement just posterior to the object followed by gentle outward pressure after balloon inflation.
• FB removal in uncooperative pediatric patients is often difficult. Repeated attempts traumatize the mucosa with subsequent epistaxis and edema limiting visualization.
• Removal by ENT under general anesthesia may be indicated in these cases. If the object is not visible or not easily removed, ENT referral is necessary.

• Patients who have had uncomplicated removal of nasal FBs are safely discharged without additional treatment or follow-up.
• Most patients who require ENT evaluation for difficult to remove items can be seen within the following 24 h. Emergent evaluation is indicated for corrosive FBs, infants with bilateral nares involvement, organic FBs and those with respiratory difficulty.

Risk Factors

• Sinusitis results from obstruction of the sinus ostia. In the majority of cases, this is secondary to viral upper respiratory infection. Other causes include allergic rhinitis, trauma, polyps, septal deviation, nasogastric/nasotracheal intubation and nasal packing. Patients with cystic fibrosis, diabetes mellitus and immunocompromise are at increased risk.
• The sinuses grow in stages. Aeration of the maxillary and ethmoid sinuses is present at birth or shortly thereafter. In contrast, the frontal and sphenoid sinuses do not begin to aerate until early childhood.

• Acute sinusitis lasts < 3-4 wk. The most common pathogens include S. pneumoniae, nontypable H. influenzae and respiratory viruses.
• Subacute disease lasts longer than 4 wk but resolves before 12 wk.
• Chronic sinusitis denotes persistence of signs and symptoms >12 wk and is usually a polymicrobial infection with organisms that are more likely resistant to ß-lactams.
• Patients with diabetes and neutropenia are at risk for fungal sinusitis such as Mucormycosis.
• Severely ill, hospitalized patients and those with indwelling nasogastric tube or nasotracheal tubes have disease caused by Gram-negative bacilli including Pseudomonas.

• Symptoms strongly indicative of acute sinusitis include facial pain, purulent rhinorrhea, dental pain, altered sense of smell and fever. Pain secondary to sinusitis increases with head movement. Nonspecific symptoms include headache, fatigue,
• otalgia and malaise. Sore throat and cough are common as a result of sinus drainage into the oropharynx. Sphenoid disease often presents as an isolated headache.
• Chronic disease has a similar presentation with low-grade symptoms that are persistent or that recur intermittently over time.
• Pertinent physical examination findings include tenderness with palpation of the involved sinus, visualization of purulent nasal secretions, fever and abnormal sinus transillumination.
• Viral rhinitis is often mistakenly diagnosed as sinusitis. Patients with bacterial sinusitis are more likely to have a poor response to decongestants, abnormal sinus transillumination, dental pain and purulent nasal discharge. Other differential diagnoses include tension headache, vascular headache, brain abscess, meningitis and intracerebral mass lesions/hemorrhage.
• Diagnosis in the ED is via clinical presentation.
  • Plain radiographs are not necessary for the diagnosis and are not recommended for routine use. If films are obtained, pertinent findings include an air-fluid level, sinus opacification and mucosal thickening but none of these findings reliably differentiates between bacterial and viral disease.

    Symptoms of sinusitis

    Sinus	Location of Symptoms
    Maxillary	Cheek/zygoma, teeth
    Ethmoid	Medial aspect of eye/orbit
    Frontal	Forehead
    Sphenoid	Retro orbital, occiput

  • CT scan provides visualization of all four paired sinuses. Indications for CT scan include: severe disease, refractory symptoms, preoperative planning and suspected involvement of contiguous structures or invasive disease.

• Antimicrobials
  • For acute disease, a 10-day course is recommended for patients with continued facial pain and purulent nasal discharge after a 7-day course of decongestants. Appropriate first-line agents include amoxicillin, trimethoprim/sulfamethoxazole, and doxycycline. Other, more broad-spectrum agents such as fluoroquinolones, macrolides, and second and third generation cephalosporins should be reserved for treatment failures. The majority of patients will eventually have symptom improvement and no complications even without antibiotics.
  • Chronic sinusitis is not usually responsive to antibiotics. Otolaryngology follow-up is indicated for patients with chronic disease.
  • Diabetic/neutropenic patients with fungal disease require hospitalization in a monitored setting and treatment with IV antifungals.
• Ancillary treatment consists of mucolytics, systemic vasoconstrictors such as pseudoephedrine, and brief use of topical vasoconstrictors. Avoid antihistamines which dry and thicken secretions. In addition, oral fluids and saline nasal sprays promote moisture and mobilization of secretions. Steroids have no proven efficacy in acute disease. Patients with sinusitis secondary to obstructing nasal foreign body such as packing should have prompt removal of the obstructing device if possible.
• Surgical indications include: acute symptoms unresponsive to antibiotics, chronic disease, invasive/intracranial disease, nasal polyposis and suspected underlying tumor.

• Most patients are discharged home with ENT follow-up.
• Admission is indicated for toxic patients, failed outpatient therapy and those in whom invasive disease in suspected. This includes those patients with facial abscesses, orbital swelling, visual disturbances, cranial nerve and/or focal neurological deficits.