Nigel Beasley, Ashok Handa, Adam Jones, and Kevin Turner explain how to deal with some ENT emergencies

Loss of the airway is a frightening event for a patient, but the treatment options are relatively simple: unblock the airway or bypass the obstruction. The tricky part is recognising that a patient in severe respiratory distress has stridor and is not asthmatic. Two other conditions which can cause concern are severe persistent epistaxis, which may result in haemodynamic shock, and otalgia caused by the potentially serious intracranial complications of acute mastoiditis.

When drastic action is needed

The most obvious cause of upper airway obstruction is an inhaled foreign body. This can be dislodged by suddenly increasing the intrathoracic pressure and forcing the obstruction out like a cork from a bottle. This is done by using Heimlich's manoeuvre: stand behind the patient and grasp him or her around the upper abdomen; an upward thrust in the epigastric region may dislodge the offending article.

Telling the difference between stridor and other causes of severe respiratory distress, including asthma and cardiac failure, is sometimes difficult. Obstruction of the upper airway results in an inspiratory or biphasic (inspiratory and expiratory) wheeze, whereas obstruction of the lower airway usually gives an expiratory wheeze. A patient with stridor will be making a great effort to breathe, have intercostal recession, tracheal tug (where the trachea seems to descend on inspiration), and little or no voice.

In children the most common cause is acute viral laryngotracheobronchitis. Epiglottitis is fortunately rare in children because of the Haemophilis influenzae B immunisation.¹ In adults laryngeal trauma, carcinoma, epiglottitis, and allergic oedema may obstruct the upper airway.

Action that you should take

Firstly, fast bleep the most senior anaesthetist resident in the hospital and explain the urgency of the problem, then call the ENT registrar. Ask for a local anaesthetic to be drawn up (0.5% lignocaine with 1:200,00 adrenaline is ideal) and for a tracheostomy set with a size 6.0 endotracheal tube to be available.

If the patient is a child try not to upset him or her - that is, do not insert a line, take blood, or arrange an x ray examination. Wait for experienced help. Heliox (20% oxygen, 80% helium) may help relieve respiratory distress in adults because of its reduced viscosity and improved laminar airflow.² Alternatively, give the patient 100% oxygen regardless of the previous respiratory state. This will increase the blood oxygen content, and if a respiratory arrest occurs you will have more time to secure an airway before there is any brain damage.

If the patient is about to expire, shown by increasing cyanosis, decreasing blood oxygen saturation, and reduced respiratory effort, you should perform a cricothyroidotomy. Reduced effort rather than increased effort is often an indicator of exhaustion and impending respiratory arrest. Do not attempt a tracheostomy. The thyroid isthmus covers the first to third tracheal rings and may cause severe bleeding if cut. Trying to find the trachea in a pool of blood is very difficult.

How to do a cricothyroidotomy

Inject a local anaesthetic into the skin overlying the cricothyroid membrane. This may seem a waste of time, but the patient will be scared and aware of what you are doing and it takes only a couple of seconds. It also means that the patient will not jump at the critical moment and cause you to miss the airway. The cricothyroid membrane is located between the thyroid cartilage above and the cricoid below (see figure).

Make a 3 cm transverse skin incision over the cricothyroid membrane and insert a green needle on a syringe into the airway. Check that you are in the airway by aspirating air and then cut down beside the needle through the cricothyroid membrane. Insert a pair of artery forceps through the hole and open them to enlarge the hole. Insert a size 6.0 endotracheal tube into the airway and continue to give the patient 100% oxygen. If this fails or facilities are not available a large intravenous cannuale (12G if possible) may be inserted through the cricothyroid membrane to give a limited airway until help arrives. Minitracn® kits are available in some hospitals.

Please remember that a cricothyroidotomy should be attempted only if respiratory arrest is imminent. Most patients are fine for the few minutes that it takes for appropriate help to arrive. Once an airway has been obtained it can be secured more formally with an endotracheal tube or tracheostomy depending on the likely need for long term intubation.

Epistaxis-nose bleeds

Epistaxis may seem innocuous, but the reality is that patients can die if not managed appropriately. The patients who are most affected are elderly people or those who are on anticoagulants and have hypovolaemic shock.

Firstly, check the pulse and blood pres- sure. If the patient is hypovolaemic (pulse >100 beats/minute, BP systolic <100 mm Hg) insert two big intravenous lines (14G or 16G), take blood for haemoglobin, clotting studies, and crossmatch four units. Start fluid resuscitation, 500 ml of colloid (Gelofusine® or Haemaccel®) stat, and call for senior help. Remember that all hospitals keep a store of group O Rhesus negative blood if your patient really is in extremis and cannot wait for blood to be crossmatched. Reassess the haemodynamic state after the infusion and continue as appropriate. Beware of overloading elderly patients as this may put them into heart failure.

Direct pressure will help

Meanwhile, take first aid measures to stop the bleeding with direct pressure. This does not involve compressing some mysterious and non-existent artery that crosses the nasal bones. Firm compression of the lower half of the nose will stop many bleeds by direct compression of the bleeding point, which is often in Little's area at the front of the nose. Ice placed anywhere on the body will result in vasoconstriction of the nasal vessels but the forehead is conventional. This should be continued for at least 20 minutes.

If after this time the bleeding has stopped and there is no haemodynamic instability the patient can be discharged with a warning to avoid hot drinks and heavy lifting or straining for a week. A follow up appointment may be arranged in the ENT clinic to cauterise any obvious vessels if it is a recurrent problem. If resuscitation is required the patient must be admitted.

Nasal cautery or a pack will be required if the bleeding continues. Without the correct facilities and a knowledge of how to use them, trying to cauterise an actively bleeding nose effectively is difficult. If you are in the accident and emergency department without immediate access to an ENT surgeon a pack will be required. The simplest is the nasal tampon (Merocel®), a highly compressed 8 cm long sponge. It is flat and rigid and usually easily inserted into the nose unless there is a gross deviation of the nasal septum. On contact with blood the sponge rapidly expands, compressing the bleeding point.

Remember that the nasal cavity goes horizontally back towards the nasopharynx for 8 cm. Trying to force a pack upwards into the nose for 8 cm will be unsuccessful unless the cribriform plate is breached. This is inadvisable. Coat the pack with lubricant - nasal antiseptic creams are good - lift the tip of the nose and aim the pack towards the opposite ear. The pack should run along the nasal septum until the end disappears into the nose. Secure the strings to the cheek and pack the other side. This is not a particularly comfortable procedure for the patient, but use of local anaesthetics in these conditions is usually ineffective. Refer for admission.

Otalgia-earache

A painful ear is usually caused by acute inflammation of the ear canal (acute otitis externa) or middle ear (acute otitis media), but referred pain from acute tonsillitis is not uncommon in children. Ask about the characteristics of the pain, any history of aural discharge, vertigo, or facial weakness. Start your examination behind the ear looking for any signs of previous surgery and then use an auriscope to look at the ear canal and ear drum.

Acute otitis externa is usually caused by wax impaction or water in the ear, particularly if the ear canal has been traumaumatised with a cotton bud, matchstick, or fingernail. The ear canal is usually red and often swollen so that the ear drum cannot be seen. The ear canal will be exquisitely tender, and pressure on the tragus in front of the ear will exacerbate the pain. Topical antibiotic and antiseptic drops will often do the trick, but if the ear canal is completely occluded referral for aural toilet and insertion of an antiseptic wick will be needed. It is becoming more common in patients with AIDS, in whom a fungal causes should be suspected.

Patients with diabetes or who are immunocompromised may have an aggressive form called malignant otitis externa that eats through the skull base picking off the cranial nerves. All these patients should be referred to an ENT surgeon.

Value of antibiotics is debatable

With acute otitis media there is usually a normal looking ear canal but an abnormal eardrum, either grey and dull or red and bulging. Pressure on the tragus will not make the pain worse. The value of antibiotics is debatable. They are usually reserved for patients who are still pyrexial and unwell despite regular paracetamol. If you are going to give an antibiotic a broad spectrum penicillin, such as amoxycillin, is best. Without treatment the eardrum may perforate and a mucopus discharge will be seen in the ear canal.

The most serious complication of acute otitis media is acute mastoiditis, as infection can spread further through the thin layer of bone separating the mastoid air cells from the cranial cavity, resulting in meningitis or intracranial abscesses. By definition all patients with acute mastoiditis will also have the symptoms and signs of acute otitis media - that is, a relatively normal ear canal and an abnormal ear drum. In addition, a fullness behind the ear and tenderness over the mastoid may be present. A persistent headache is the commonest symptom of an intracranial complication.

All suspicious cases should be seen by an ENT surgeon. Intracranial complications are more common when the ear is chronically discharging. The onset of otalgia in this group is highly suspicious of acute mastoiditis, and the presence of nystagmus or a facial palsy would suggest extension of the infection to involve the vestibular apparatus or facial nerve. This must be referred immediately.

1. Midwinter KI, Hodgson D, Yardley M. Paediatric epiglottitis: the influence of the Haemophilis influenzae b vaccine, a ten-year review in the Sheffield region. Clin Otolaryngol 1999;24:447-8.
2. Fleming MD, Weigelt JA, Brewer V, McIntire D. Effect of helium and oxygen on airflow in a narrowed airway. Arch Surg 1992;127:956-9