In this article, we cover the main ENT situations you are likely to encounter either in A&E, during an ENT on call job or occasionally as a ward emergency. ENT cases can be exciting but slightly daunting, particularly due to the number of specialty-specific presentations and practical procedures to become familiar with as well as the potential for patients to have airway concerns. Scroll down to the topic you're interested in:
  • Airway emergencies
  • Epistaxis
  • Tonsillitis & quinsy
  • Post tonsillectomy bleed
  • Pinna haematoma
  • Mastoiditis
  • Orbital cellulitis
  • Septal haematoma
Like everything else, a good history and examination will get you far. You will become increasingly confident as you see more ENT cases, but know the ENT seniors are expecting to be called to help as necessary. 

Acute Airway Management
An acute airway emergency can be a very stressful situation. Remembering these simple but key points will help you to manage the situation until senior help arrives:
  • Ensure the anaesthetic team have been called/medical emergency call has been put out. This patient may need advanced airway manoeuvres, adjuncts, intubation or a tracheostomy
  • Ensure the patient is either in resus or the resuscitation trolley is by the patient if on the ward
  • Review the patient promptly. Get a brief AMPLE history from surrounding staff, friends or relatives (Allergies, Medication, PMH, Last meal (time), Events surrounding the injury/illness)
  • Complete your A to E assessment
    • Ensure you give the patient 15L of oxygen via non-rebreathe mask
    • Keep the patient calm & sit them upright looking out for
      • Stridor - high-pitched inspiratory noise caused by obstruction at the larynx. A biphasic stridor can occur in tracheal obstruction
      • Stertor - low-pitched inspiratory noise due to obstruction at the oropharnyx
  • Consider nebulised adrenaline (1ml in 1:1000 in 4ml of 0.9% sodium chloride) & IV dexamethasone (6.6mg for adults). This will buy time by reducing upper airway swelling.
  • Consider & treat obvious causes e.g. foreign bodies, anaphylaxis 
  • Bloods, inflammatory markers & cultures if septic
If you are reviewing the patient as part of the ENT team, collect the flexible nasoendoscope (FNE) and ensure your seniors are attending this call with you. FNE should be performed when the patient is stable enough, but also note that it can cause laryngospasm and thus compromise the airway. Hence in this situation, FNEs should be performed by a senior. 

Depending on the history, potential causes include:
  • Infections e.g. Ludwig’s angina (floor of mouth), quinsy, deep neck space abscesses
  • Inflammatory reaction e.g. angioedema, trauma, tumours
  • Iatrogenic e.g. recurrent laryngeal nerve damage (affecting cord function) or a haematoma causing compression – consider these particularly if called to see a patient in post-op recovery

Epistaxis
This topic is covered in more detail here. You are likely to encounter patients who develop epistaxis in whatever specialty you choose to do. Non-specialists can often find it challenging to manage nosebleeds from lack of experience. Most bleeding is from the anterior septum (Little’s area).


Basic first aid/initial management of all epistaxis:
  • The soft part of the nose should be pinched firmly and pressure kept for 15-20 minutes without releasing (the temptation is to keep checking if it has stopped, don’t do this).
  • The patient should lean their head forward and encourage them to spit out any blood rather than swallowing it (blood is emetogenic) 
  • If available, an ice pack can be placed on the bridge of the nose or back of their neck
  • Do not underestimate a nosebleed! Bleeding can be significant or life-threatening. If concerned, ensure you escalate early
  • Check the oropharynx for ongoing bleeding (you can ask them to gargle water to help with this assessment) 
There is a simple management ladder for epistaxis, however, advanced steps should be done by someone with sufficient expertise
  1. Basic first aid 
  2. Nasal cautery – using co-phenylcaine (blue case) spray 
  3. Unilateral anterior packing 
  4. Bilateral anterior packing 
  5. Posterior nasal packing – get help if you haven’t already 
  6. Surgery or sometimes angiography and embolization
If a patient does require packing, they require admission & will need analgesia (to prevent headaches).

Other Considerations: 
  • IV access
  • Bloods: check FBC, clotting if on anticoagulation, send G&S
  • Management of hypertension
  • Consider management of anticoagulation – is INR out of range? Is it appropriate to pause anticoagulants? In severe intractable cases, pharmacological reversal of anticoagulation may be needed.
  • There is no need/little point in withholding antiplatelet drugs as they take several days to wash-out

Tonsillitis & Quinsy
Acute tonsillitis is an infection of the palatine tonsils, commonly seen in children and young adults.
It typically presents with sore throat, painful swallowing, dysphagia, earache, malaise and fever. It is very common.
  • In 70% it has a viral cause
  • Bacterial tonsillitis is largely caused by Group A beta-haemolytic streptococci
    • There is a 50% chance of it being bacterial if: pus on tonsils, pyrexial, no cough and tender cervical lymphadenopathy
    • Antibiotics should be given if 3 or more of these are present (Centor Criteria).
Quinsy is a peritonsillar abscess. Patients typically present with painful swallowing, dysphagia, fevers, difficulty opening their mouth (trismus). They may have a history of previous episodes of tonsillitis or quinsy.

Examination:
  • Tonsillitis: bilateral tonsillar swelling with white patchy exudate, may have altered voice, cervical lymphadenopathy.
  • Quinsy: unilateral swelling of peritonsillar region, trismus, uvula deviation away from the quinsy, change in voice, cervical lymphadenopathy

It can sometimes be difficult to be certain on examination and many of the referrals for quinsy turn about to be tonsillitis - don’t worry if initially, you’re not sure, that’s normal – once you’ve seen a few you’ll feel much more confident.

The appearance of the anterior palatopharyngeal arch can give you a good idea:
  • Tonsillitis – swelling is of the tonsils between the arches, so you should be able to see the anterior arch in a relatively normal position
  • Quinsy – the anterior arch will be pushed medially due to the abscess
Investigations: FBC, U&Es, glandular fever screen (also known as monospot or Paul-Bunnel test), CRP, blood cultures (if pyrexial)

Management:
  • ABCDE & fluid resuscitation if septic
  • Analgesia – regular painkillers, including Difflam Spray & Difflam 0.15% oral rinse
  • Antibiotics as per trust guidelines (often benzylpenicillin or Penicillin V)
  • IV Dexamethasone (6.6mg in adults) if concerned about significant inflammation (discuss with seniors as needed)
Admission or Discharge
Often patients are given a trial of IV treatment then discharged on orals after 2-3 hours of observation. If a patient is unable to swallow liquids/tablets after this initial treatment, they should be admitted. The patient should be able to eat & drink and their observations should be in range. 

For quinsy, they usually require drainage which is usually done in ED. This can re-accumulate therefore they are admitted in case further drainage is required. You are usually taught how to drain the abscess in quinsy.

Glandular Fever Pointers and Advice:
  • Examine the abdomen: ?hepatosplenomegaly
    • If LFTs are deranged and worsening – consider USS Liver
    • If deranged on discharge – ask GP to follow up/arrange repeat
  • Avoid alcohol
  • Avoid contact sports for at least 6 weeks
  • Likely to feel tired and lethargic for longer than bacterial tonsillitis patients
  • Ensure all discharge advice is documented in the discharge letter!
Final Points
  • This is bread & butter ENT. You will be starting treatment and assessing the suitability of discharge frequently. Normal observations & being able to eat/drink are very reassuring from this perspective
  • Consider the SIGN criteria for tonsillectomy - this includes
    • 7 or more episodes in the preceding 12 months requiring antibiotics
    • 5 or more per year (in the past 2 years)
    • 3 or more per year (in the past 3 years)

Post Tonsillectomy Bleed
This is an emergency and needs quick assessment, resuscitation and intervention. Patients occasionally need to be taken back to theatre urgently to control the bleeding. It is best to call the registrar as soon as you get this call, even if you are told the bleeding has currently settled, so they are at least aware.

Post tonsillectomy bleeds can be defined as primary (within 24 hours of tonsillectomy) or secondary. 

If in A&E, these patients must not leave majors/resus (even if the bleeding has settled in or prior to ED) as it can easily restart with serious consequences.

Management:
  • If they are actively bleeding, call to update your Registrar immediately.
  • Ensure large-bore IV access (get help with this if needed!)
  • Bloods including FBC, U&Es, CRP and group and save/crossmatch should be sent.
  • This can be done whilst taking an AMPLE history
Initial treatments:
  • ABCDE & fluid resuscitation
  • Hydrogen peroxide gargles (ask a nurse to get this for you ASAP); this will control most cases of post-tonsillectomy bleed
  • Tranexamic acid (if not contraindicated)
  • IV antibiotics (often have infection of the tonsillar bed)
  • Keep NBM
If bleeding is heavy and not slowing with H2O2 gargles, attempt to control the bleeding with adrenaline-soaked gauze pressed into the tonsillar fossa. But if you are needing to do this, they often need a trip to theatre to control the haemorrhage surgically

All post-tonsillectomy bleeds should be admitted for observation, even if the bleeding has stopped – prescribe hydrogen peroxide gargles PRN in case of further bleeds.


Pinna Haematoma
Pinna haematomas are mostly seen following trauma with blood collecting in the subperiosteal space. As the cartilage receives its nutrient supply from the overlying perichondrium, an untreated pinna haematoma results in necrosis of the cartilage and permanent deformity (cauliflower ear). Early presentation and review are therefore important. 

Do review for any other injuries & review any anticoagulation


Management:
  • ENT team will need to consent the patient for incision & drainage under local anaesthetic
  • They will sometimes attempt needle aspiration followed by compression, but this is associated with high failure rates
  • Various suture techniques, silastic splint or dental roll may be used to reduce the risk of recollection with a head bandage to secure the dressings in place
  • Antibiotics (such as co-amoxiclav or equivalent) are given to prevent perichondritis. 
  • Follow up in the ENT acute/emergency clinic for review in 3-5 days following discharge

Mastoiditis
This is a relatively commonly referral from GPs and requires patients to be seen urgently. This condition describes an inflammatory process affecting the mastoid air cells and is a potential complication of acute otitis media. It most commonly affects children. Patients are typically unwell with fevers.

Examination:
  • Can range from post-auricular erythema, to boggy swelling, or a fluctuant abscess
  • Pinna may be displaced outwards and forwards
  • Tenderness alone over the mastoid bone does not indicate mastoiditis.
Management:
  • Admission
  • Most cases respond well to IV antibiotic management (see your local guidelines).
  • If the patient is not responding well after 24-48 hours of IV antibiotics or there are concerns of complications, then a CT temporal bones with contrast should be arranged.
  • Complications include cerebral abscess and lateral sinus thrombosis.
  • The CT also helps with surgical planning. The surgical procedure often required is a cortical mastoidectomy and grommet insertion

Orbital Cellulitis 
This is an emergency presentation which can cause blindness. The infection commonly starts from the sinuses after a recent upper respiratory tract infection - which is why ENT are involved.

As this is typically seen in children it is important to involve paediatrics and ophthalmology, especially as examining the distressed child is likely to be challenging.

Presentation:
  • Patients classically present with eyelid swelling.
  • There may be chemosis and proptosis.
  • Examination should include visual acuity, pupillary reactions, colour vision assessment and eye movements.
  • Restricted eye movement or pain on eye movement is a sign that there is likely to be an abscess.
Management:
  • IV antibiotics (often third-generation cephalosporins but see local guidelines)
  • Analgesia
  • Urgent CT scan of the orbits and paranasal sinuses
  • If evidence of sinus disease, prescribe a nasal decongestant
  • Surgical drainage may be needed and is often performed endoscopically

Septal Haematoma/Abscess
Nasal Injuries do not need to be seen the same day unless there is concern that there is a septal haematoma. These often grow rapidly and are associated with pain and nasal obstruction symptoms.

Examination:
  • Bilateral septal swelling which is boggy on palpation (tip: use a swab tip to palpate the swelling to see if it is firm/soft/boggy).
  • The haematoma can become infected causing an abscess.
  • Suggestive features include increasing pain, fever and purulent nasal discharge.
  • It is not uncommon for confusion occurring due to a deviated nasal septum but this will not be boggy
From the BMJ

If a haematoma is present, this needs same day incision & drainage and antibiotics. The septal cartilage gets its blood supply from the within the surrounding mucoperichondrium. Delays in drainage of a haematoma can lead to avascular necrosis of the cartilage and permanent deformity.

Very rarely, if drainage of the abscess is delayed the infection can spread intracranially via the ophthalmic veins and lead to cavernous sinus thrombosis.

References and useful sites
Written by Emma Richards (ENT SHO)
Reviewed & edits by Edward Balai (ENT SHO)