PPO:ENT

Emergencies

Ear

• Sudden Sensorineural Hearing Loss

(SSNHL)

• TM rupture
• Temporal Bone Fracture
• Malignant Otitis Externa
• Mastoiditis

Nose

• Nasal fracture
• Epistaxis
• Nasal foreign body
• Midfacial trauma
• Sinusitis

Upper airway

• Peritonsillar abscess
• Deep neck abscess
• Post-tonsillectomy bleed
• Complex facial lacerations

Communication

1. ENT Physician on Call- -call or text with expected response time of 30 min or less

2. ENT Physician Not on Call -if post-op case call/text responsible physician first -if ER Physician deems urgent may text both surgeons. If no response ER Physician should call ENT ( On Call 24hr/day ) at Kelowna General Hospital (KGH)

Sensorineural hearing loss

Pearls - Pt presents with acute onset of hearing loss, always unilateral - “woke up with it” - Tinnitus, aural fullness, balance disturbance - Plugged or congested feeling - No otalgia - Preceding URTI common - TRUE OTOLOGIC EMERGENCY - Normal Otoscopy - Tuning Fork exam confirmative

Management 1. Explain suspected Diagnosis and time- sensitive nature 2. Initiate Prednisone 50-60mg PO OD x 7 days

3. Contact ENT on-call OR if no ENT available Fax Referral marked URGENT 4. Patient to call WILDHORSE SURGICAL immediately – give contact info 5. Urgent audio as soon as possible to confirm Dx 6. ENT consult, follow-up audiogram, MRI (typically arranged by ENT)

TM perforation

Pearls - Typical etiology Q-tip, watersport, slap/punch, acoustic trauma - Immediate onset hearing loss, tinnitus, otalgia, bloody otorrhea, balance disturbance - Otoscopy may reveal perforation - Tuning fork exam typically confirms conductive loss - NOT time-sensitive Management 1. Discuss suspected diagnosis and reassure NOT time-sensitive and most will often recover with no intervention required

2. No immediate imaging or bloodwork needed in typical case 3. DO NOT flush , DO NOT clean 4. Maintain dry ear precautions until seen by ENT 5. CIPRODEX Otic drops tid x 7 days – helpful for prevention/control of infection and analgesia 6. Fax referral to WILDHORSE SURGICAL 7. Pt will be contacted for ENT consult, audiogram, imaging, definitive management

Nasal fracture

Pearls - Common to all ER departments - Typically a result of blunt midface trauma - Time – sensitive management - closed reduction and splinting within 7 days - Midfacial edema may hide significant cosmetic deformity - Beware septal hematoma on anterior rhinoscopy

Management

1. Reassure patient and family common and very fixable injury yet TIME SENSITVE

2. Hx and Phx will establish level of concern regarding other possible craniofacial injuries 3. No imaging needed in typical case 4. Rest , ice critical to reduce swelling in first 48-72 hrs 5. Urgent ENT referral can be faxed to WILDHORSE Surgical 6. Patient will be contacted immediately for consult/definitive management in OR-ACU

Epistaxis

Pearls - Rarely life-threatening - Typically low-volume anterior bleeds - Kisselbach’s plexus most common - Anterior vs Posterior differentiation determines approach and management options - ABC’s , IV access , Team approach for significant posterior bleed necessary - Full PPE important - In cases with anticoagulants or coagulopathy bleeds often multifocal and best respond to packs

Management 1. Remove all clots ( nose blow vs suction) 2. Apply pressure w nasal clamp – 15min 3. Assemble equipment – epistaxis tray, headlight, PPE 4. Localize nostril w 4% Lidocaine-Otrivin soaked pledgets 5. If bleed is visible may attempt cautery ( AgNO3) – if not suggest pack 6. Rapid Rhino 5.5cm best for anterior bleeds – 7.5 cm best for posterior bleeds 7. Insertion of pack made easier w lubricant (Polysporin), should be left in place 72 hrs 8. Patient should return to ER or clinic for removal, reduce pressure and wait 30 min. No further bleed remove pack – if further bleeding re-inflate, call ENT for further direction 9. Consideration should be given to role for: Tranexamic acid Antibiotics Stopping anticoagulants

Post-tonsillectomy bleed

Pearls - Considered an E1 surgical emergency - Risk of hemorrhage in our region approx. 1% - based on 15 yr. data pool at EKRH - Classified as primary ( within 24 hrs ) or secondary - Gross majority of bleeds are minor and self- limiting - Rarely life- threatening

Management 1. Pt should be sitting upright in bed, suction available 2. History important to direct level of intervention needed

3. Significant bleed will require ABCs, IV access, CBC, Crossmatch, ENT consult 4. Examine oral cavity to look for active bleed vs clot in tonsil fossa 5. DO NOT REMOVE CLOT unless airway compromising 6. Consult ENT on call for direction – if no local ENT on call please call or text local ENT for response- if no immediate response and help is required urgently call ENT Kelowna 7. ACTIVE BLEED in hemodynamically unstable patient- Direct pressure with gauze pack soaked in Adrenaline 1mg/ml(1:1000) and urgent Anaesthesia consult 8. If no active bleed and patient stable a period of observation is needed 4-6 hrs – clear fluid diet x 12 hours