Tag Archives: ENT

Ultrasound in Tonsillitis – Submandibular Approach (Transcutaneous)

Posted on by

PoCUS Clinical Pearl by Dr. Rawan Makhdom

DalEM PoCUS Fellow

Reviewed by Dr. D Lewis

Copy Edited by Dr. D Lewis

Pdf Download: EMSJ RMakhdom Ultrasound in Tonsillitis – Submandibular Approach

Case

A 33-year-old gentleman presents to the ED with a history of fever and sore throat for the past week.

Seven days ago, he was diagnosed with tonsillitis and started on Amoxicillin but showed no clinical improvement.

Three days ago, his antibiotic was changed to Azithromycin.

At his present visit, he is febrile with a complaint of sore throat and muffled voice.

 

 

 

Background

Tonsillitis is an infection or inflammation of the tonsils. The tonsils are areas of lymph tissue on both sides of the throat, above and behind the tongue. They are part of the immune system, which helps the body fight infection. Tonsillitis is usually self-limiting, with most patients recovering within 4 to 10 days. Tonsillitis is usually viral, but can be bacterial e.g., strep throat and in rare cases, a fungus or a parasite can cause tonsillitis. The main symptoms of tonsillitis are a sore throat, and swollen tonsils. Symptoms may also include a fever, a congested or runny nose, swollen lymph nodes, a headache, and trouble swallowing.

 

Figure 1: Normal vs Inflamed Tonsils. (Mayoclinichealthsystem.org)

 

  • Peritonsillar Abscess (PTA) is one of the most common deep neck space infection
  • PTA is a potentially life-threatening complication if not treated.
  • Blind aspiration can lead to eroding or extending of the pus into the deep tissues of the neck, carotid sheath, or posterior mediastinum.

 

Can PoCUS help?

  • The ability of clinicians to reliably differentiate PTA from peritonsillar cellulitis (PTC) by physical examination alone is limited. (2)
  • Both conditions can have overlapping clinical presentations and findings; however, these 2 conditions have very different treatment regimens.
  • Blind needle aspiration is the typical method of choice to diagnosis a PTA, has also been found unreliable with a reported false-negative rate of 10% to 24% (2)
  • So, POCUS can help to differentiate and can also help with needle aspiration!

 

Endocavity Approach (Intraoral)

Figure 2: Ultrasound of Normal Tonsil using Endocavity Approach. (Google images)

 

Technique:

  • The probe is placed into the mouth against the affected tonsil to visualize any adjacent collection.
  • The transducer should be covered with either a condom or a finger from a sterile glove filled with ultrasound gel.
  • A topical anesthesia can be applied (spray) to the oropharynx prior to the examination.

Advantages:

  • It can aid the efficacy and safety of aspiration by localizing the area of pus and visualizing the relationship of the abscess to the carotid artery.

Disadvantages:

  • Not all EM providers have access to an endocavity probe.
  • The patient may also have trismus or difficulty opening their mouth wide enough to accommodate the endocavity probe.
  • Some patients simply cannot tolerate the oral ultrasound.

 

Submandibular Approach (Transcutaneous)

 

Technique:

  • Curvilinear/ linear probe was placed under the patient’s mandible.
  • Marker toward the patient’s ear.
  • Fanned to locate the tonsils.
  • Transverse plane/longitudinal plane (1,5).


Figure 3: Submandibular Approach for Scanning Tonsils using High Frequency Probe. (Brown Emergency Medicine brownemblog.com)

 

Endocavity vs Submandibular Approach

Comparing the two different techniques, intraoral had a sensitivity and specificity of 91% and 75% while transcervical (TCU) had a sensitivity and specificity of 80% and 81% (4).

 

PTA PoCUS Pearl

  • When there is doubt, evaluate the contralateral side.
  • Locate the internal jugular vein and carotid artery and fan the transducer cephalad.
  • with the tonsil appearing laterally and adjacent to the hyperechoic oropharyngeal space.
  • Ask the patient to swallow.
  • Using color Doppler can help identify vascular flow from the internal carotid as well as inflamed tonsillar tissue.
  • As most PTAs are superior and posteriorly located, these will appear deep on transcutaneous views.

 

Figure 4: Ultrasound of PTA using Linear Probe. (SJRHEM)

 

Figure 5: Ultrasound of PTA using Curvilinear Probe. (SJRHEM)

 

Figure 6: Another Ultrasound of PTA using Linear Probe. (SJRHEM)

 

References

  1. Mathew Lecuyer “What is that hot potato voice? POUCS for the PTA” 3 May, 2019. http://brownemblog.com/blogposts/2019/4/24/ptaultrasound
  2. Michael Secko MD a, et al. “Think Ultrasound First for Peritonsillar Swelling.” The American Journal of Emergency Medicine, 23 Jan. 2015. sciencedirect.com/science/article/abs/pii/S0735675715000339.
  3. Matti Sievert, et “the value of transcutaneous ultrasound in the diagnosis of tonsillar abscess: A retrospective analysis” 6 Dec, 2021. https://www.sciencedirect.com/science/article/abs/pii/S0385814621001279
  4. Daniel J. Kim MD a ,et “Test Charcteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta-analysis” 10 Jan, 2023. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14660
  5. Hiroshi Hori, MD, et “The effectiveness of transcutaneous cervical ultrasonography for diagnosing peritonsillar abscess in patient complaining of sorethroat” 22 Jan, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796778/
Continue Reading

Peritonsillar Abscess Considerations and Treatment

Posted on by

Flimsy on Quinsy: Considerations and procedures to help diagnose and treat peritonsillar abscess  

Author: Iain McPhee- PGY1

Case study:

A 30 y.o. female presented to the emergency department with a 2-3 day history of sore throat, a unilateral, right sided oral pain that was worsening, and mild right ear ache. Although she was able to swallow food and liquid with discomfort, she reported an increased pooling of saliva in her mouth. She became more concerned when she noticed voice changes and decided to come to the hospital. 

On exam, she looked well and her vitals were within normal limits. On examination of the oral cavity there was a noted mild deviation of the uvula to the left. There was clearly demarcated erythema of both the hard palate and soft palate on the right side. Her right tonsil was only mildly enlarged and the presence of tonsillar stones were appreciated bilaterally. There was very mild fluctuance when palpating the junction between the hard and soft palate. There was an obvious dysphonia (Hot potato voice).

Background:

Peritonsillar abscess (PTA) (Quinsy) and peritonsillar cellulitis (PTC) are often indistinguishable, sharing similar clinical signs and symptoms (1). As management differs depending on the condition, several aspects warrant consideration in the differentiating process

Considerations: 

  1. Assess for severe upper airway obstruction
    • Look for signs of trismus, suprasternal retractions and anxious appearance. If present consider airway management.
  2. Computed tomography of the neck
    • Consider if you suspect signs of deep neck infection like a retro or parapharyngeal abscess. The CT scan should be obtained with contrast to help identify an abscess (4)
  3. Ultrasound guided exam 
    • Intraoral ultrasound has been shown to be a superior method to both diagnose and assist in the execution peritonsillar abscess drainage when compared to classic landmark-based needle aspiration (2,3). 
  4. Time
    • In the absence of a significant/apparent fluctuating mass in the mouth, consideration of the amount of time the symptoms have been present can help distinguish between the two conditions. Peritonsillar cellulitis is considered a transition phase of peritonsillar inflammatory process which leads to abscess formation (1). Look for 1-2 day history of symptoms as peritonsillar cellulitis, Abscesses are more likely to form between 2-8 days.

Algorithm: Approach to diagnosis and treatment of peritonsillar abscess in the emergency department

https://www.uptodate.com/contents/image?csi=59e98f58-4a45-4ff2-b021-31528346c088&source=contentShare&imageKey=EM%2F112062

Intraoral Ultrasound approach to drainage (as described on emdocs)

http://www.emdocs.net/unlocking-common-ed-procedures-peritonsillar-abscess-drainage/

  1. Use intracavitary probe with cover (Fig 1).
    • Examine affected area and locate abscess 
    • Also locate depth of carotid artery and any potential vascular anatomy anomalies (Fig 2).

      Figure 1: Intracavitary Probe with cover

      Figure 2: Anechoic abscess and carotid artery highlighted in red

       

  2. Analgesia/anesthesia
    • Consider IV analgesia, anxiolytics
    • Anesthetize oral cavity using topical spray like cetacaine or nebulized lidocaine
    • Inject lidocaine with epinephrine into the area of abscess with 18g needle with cut sheath (Fig 3).

      Figure 3 : Scalpel with taped guard and

  3. Optimize Abscess visualization 
    • Insert laryngoscope blade to a depth that is comfortable for the patient. Ask patient to hold laryngoscope (Fig 4)

      Figure 4: Laryngoscope blade optimizing view

  4. Drainage
    • Once adequate visualization is achieved, approach superior pole of abscess with sheathed spinal needle and continuously aspirate when advancing until pus is reached (Fig 5).
    • Consider incision with scalpel with protective guard and used 
    • Insert curved hemostat into abscess space to break up remaining loculations

      Figure 5: Anatomical picture showing superior pole

 

References

  1. Mohamad I, Yaroko A. Peritonsillar swelling is not always quinsy. Malays Fam Physician. 2013 Aug 31;8(2):53-5. PMID: 25606284; PMCID: PMC4170468.
  2. Costantino TG, Satz WA, Dehnkamp W, Goett H. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg Med. 2012 Jun;19(6):626-31. doi: 10.1111/j.1553-2712.2012.01380.x. PMID: 22687177.
  3. Froehlich MH, Huang Z, Reilly BK. Utilization of ultrasound for diagnostic evaluation and management of peritonsillar abscesses. Curr Opin Otolaryngol Head Neck Surg. 2017 Apr;25(2):163-168. doi: 10.1097/MOO.0000000000000338. PMID: 28169864.
  4. Galioto NJ. Peritonsillar abscess. Am Fam Physician. 2008 Jan 15;77(2):199-202. PMID: 18246890.

Procedures and Algorithms

  1. http://www.emdocs.net/unlocking-common-ed-procedures-peritonsillar-abscess-drainage/
  2. https://www.uptodate.com/contents/image?imageKey=EM%2F112062&topicKey=EM%2F6079&search=peritonsillar%20cellulitis&rank=1~19&source=see_link

 

Continue Reading

Ear Foreign Body Removal

Posted on by

Ear Foreign Body Removal

Resident Clinical Pearl (RCP) May 2020

Dr. Sultan Alrobaian (PEM Fellow and Dalhousie PoCUS Fellow, Saint John, NB, Canada)

Reviewed by Dr. David Lewis

Introduction

  • Most patients with ear Foreign Bodies (FB) are children, adults can also present with ear FB
  • The most common objects removed include beads, pebbles, tissue paper, small toys, popcorn kernels, and insects
  • Diagnosis is often delayed because the causative event is usually unobserved or the symptoms are nonspecific
  • Most of the patients with ear FBs were asymptomatic at presentation, other patients presented with otalgia, bleeding from the ear, otorrhea, tinnitus, hearing loss, a sense of ear fullness or symptoms of otitis media
  • Successful removal depends on several factors, including location of the foreign body, type of material and patient cooperation
  • Visualization of a foreign body on otoscopy confirms the diagnosis, the other ear and both nostrils should also be examined closely for additional foreign bodies.

Clinical Anatomy

© 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Equipment

  • Multiple options exist for removal of external auditory canal foreign bodies
  • Which piece of equipment to use will be influenced by the type of FB, the shape of the FB, the location of the FB and the cooperativeness of the patient

Timing

  • The type of foreign body determines the timing for removal
  • Button batteries, live insects and penetrating foreign bodies warrant urgent removal

Indications for consultation or referral to a specialist

  • Button battery
  • Potentially penetrating foreign bodies
  • Foreign body with evidence of injury to the external ear canal (EAC), tympanic membrane, middle ear, vestibular symptoms or marked pain

Technique

1 – Irrigation

  • This technique is used for small inorganic objects or insects
  • Irrigation is often better tolerated than instrumentation and does not require direct visualization
  • Contraindicated in patients with tympanostomy tubes, perforated tympanic membranes or button battery because the potential for caustic injury.
  • An angiocatheter or section of tubing from a butterfly syringe
  • Using body temperature water, retract the pinna, and squirt water superiorly in the external auditory canal, behind the FB

© 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

2 – Instrumentation under direct visualization

  • Instrumentation can be painful and frequently warrants procedural sedation in young children or other uncooperative patients
  • General anesthesia may be required to ensure safe removal
  • Restrain if needed for safety

  • Commonly used pieces of equipment are curettes, alligator forceps, and plain forceps. Other equipment options include using a right angle hook, balloon catheter, such as a Fogarty catheter

  • Used in conjunction with the operating head of an otoscope
  • The pinna should be retracted, and the FB visualized
  • When using forceps, the FB can be grasped and removed

  • Both curettes and right angle hooks should be gently maneuvered behind the FB and rotated so the end is behind the FB, which can then be pulled out

© 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

3 – Suction

  • This should be performed with a soft suction tipped catheter that has a thumb controlled release valve
  • Insert the suction against the FB under direct visualization and then activate the suctions and remove the FB

© 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

4 – Cyanoacrylate

  • Apply a small amount of cyanoacrylate or skin glue to the blunt end of a cotton-tipped applicator
  • Insert it against the FB under direct visualization and hold in place until the glue dries
  • Slowly and carefully withdraw

5 – Insect removal

  • The first step is to kill the insect with mineral oil followed by lidocaine
  • Once the insect is neutralized, it can be removed by any of the above methods

SUMMARY

  • Foreign bodies of EAC frequently occur in children six years of age and younger
  • Patients with foreign bodies of the EAC are frequently asymptomatic
  • Button batteries , penetrating foreign bodies or injury to the EAC should undergo urgent removal by an otolaryngologist.
  • With adequate illumination, proper equipment, and sufficient personnel, many EAC foreign bodies can be removed

REFERENCES

1.Lotterman S, Sohal M. Ear Foreign Body Removal. [Updated 2019 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459136/

2.https://www.uptodate.com

3.Heim S W, Maughan K L. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(08):1185–1189. [PubMed] [Google Scholar]

4.Awad AH, ElTaher M. ENT Foreign Bodies: An Experience. Int Arch Otorhinolaryngol. 2018;22(2):146–151. doi:10.1055/s-0037-1603922

Continue Reading

Epistaxis Management in the ED – 3 Step Method

Posted on by

Epistaxis Management

Resident Clinical Pearl (RCP) – December 2018

Luke Taylor R3 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. Kavish Chandra

 

It’s 0300 and you are on a solo night shift when a 76 year old male with blood dripping out of both nares is brought into an examining room. It looks a little more profuse than what you saw on Stranger Things last month, but you are also wondering how to best tackle this very common emergency problem

 

History

-Laterality, duration, frequency

-Estimated blood loss, presence of any clots?

-Inciting factors such as trauma or coagulopathy

-Past medical history, especially hypertension, clotting disorder, HHT

-Medications such as anticoagulants or anti-platelets

 

Physical examination

-Have patient blow nose or use suction to clear clots

-Do not try and visualize until decongestion complete

-Visualize with nasal speculum for site of bleeding. If an anterior bleed, most commonly the bleeding site will be Little’s area (Figure 1)

-See below for management if patient’s ABCs stable. If unstable be prepared to secure airway and call for help – ENT/interventional radiology

 

Figure 1. Nasal vascular anatomy, adapted from https://www.juniordentist.com/what-is-littles-area-or-kiesselbachs-area-and-the-arteries-in-it.html.

 

Management

-Get IV access, draw CBC and coagulation profile when indicated

-Treat as unstable until proven otherwise

 

Pearls

  • Apply ice to the hard palate (popsicles, ice in the mouth) to reduce nasal blood flow up to 25%
  • TXA in patients on anti-platelets (primarily aspirin) results in faster cessation of bleeding
  • Ducanto suction in future -> SALAD technique – Ducanto-bougie intubation for large bleeds
  • Only reverse anticoagulants if absolutely necessary – “local problem, local solution”

 

Three Step Approach to Epistaxis

1. Visualize and decongest

  1. Have patient blow their nose to clear all clots
  2. Visualize nasal cavity and oropharynx now and with each reassessment for source of bleeding. Don’t forget to wear mask and use a headlamp
  3. Soak cotton balls or pledgets in lidocaine with epinephrine and 500mg of tranexamic acid
  4. Pack nose with soaked cotton and replace clamp for 10 mins

2. Cauterize

  1. Remove clamp and packing
  2. Area should be well blanched and anesthetized
  3. Visualize plexus and cauterize proximal to bleeding area for 10 sec max AND never both sides of septum (higher risk of septal perforation)
  4. If successful and bleeding ceases on reassessment, apply surgicel wrapped around a small piece of surgifoam to create a “dissolvable sandwich”and discharge home

3. Tamponade

  1. Apply unilateral nasal packing (Rapid Rhino, Merocel, etc)
  2. Reassess in 10 mins, visualizing oropharynx for continued bleeding
  3. If stops, can discharge home with packing in place and follow up in ED or ENT clinic in 48hrs for removal. No antibiotics required in immunocompetent patients.
  4. If continues to bleed, move the patient to a higher acuity area and apply bilateral nasal packs

When to call ENT

If bilateral nasal packing bleeding continues, assume posterior bleed and initiate resuscitation, draw labs (CBC, coagulation profile, cross-match if not already done). Reverse known coagulopathy and consult for OR or embolization.

 

ED Rounds – Epistaxis

 

 

References:

Dr Christopher Chin and his informative talk

http://rebelem.com/topical-txa-in-epistaxis/

https://emergencymedicinecases.com/ent-emergencies/ 

https://lifeinthefastlane.com/epistaxis/

 

This post was copyedited by Kavish Chandra @kavishpchandra

Continue Reading

Pharyngitis

Posted on by

“Doc, you gotta’ help me”: corticosteroids as an adjuvant for pharyngitis

Resident Clinical Pearl – December 2015

Kavish Chandra, R1 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by: Dr Matt Greer and Dr David Lewis

Pharyngitis is a common presenting complaint in the EDs and primary care practices. The etiology of pharyngitis most commonly is viral in origin (rhinovirus, coronavirus and adenovirus); however, other infectious etiologies include bacteria, fungi and parasites.1 Of the bacterial causes, group A beta-hemolytic Streptococcus (GABHS) is the most common pathogen, representing 15% of pharyngitis cases in adults and 15 to 30% in children (1).

 stst2

 

There are several treatment algorithms for the treatment of GABHS, and varying treatments for the other etiologies of pharyngitis. While physicians often assume that patients are seeking antibiotics for the treatment of their pharyngitis, a major treatment goal for patients is to improve their pain and swallowing.2 Some advocate for the addition of a single dose of dexamethasone in moderate to severe cases, which may shorten the duration of pain (2).

 

The Question:

How effective are corticosteroids as an adjuvant in the treatment of pharyngitis?

A Cochrane review in 2012 looked 8 randomized-controlled trials which included 743 adult and pediatric patients with tonsillitis, pharyngitis, sore throat and/or odynophagia treated with either corticosteroids or placebo (3). The meta-analysis included out-patients in the ED or in primary care practices and excluded in-patients, patients with infectious mononucleosis, post-surgery or peritonsillar abscesses. Primary outcomes were: resolution of pain and mean time to onset of pain relief. Corticosteroids included betamethasone (8mg), dexamethasone (up to 10mg) or prednisone (60mg), and were administered either orally or intramuscularly. All patients received antibiotics and other analgesia. In addition to antibiotics and analgesia, the administration of corticosteroids increased the likelihood of complete pain resolution at 24 hours by 3.2 times and by 1.7 times at 48 hours, NNT of 3.3 and 3.7 respectively. The administration of corticosteroids reduced the mean time to onset of pain relief by 6 hours and 14.4 hours for complete pain resolution. There were no differences in adverse effects in the corticosteroid and placebo groups.

 

Limitations of the review: all patients were treated with an antibiotic and analgesia in addition to a corticosteroid in the treatment arm. Therefore, studies are needed to assess the effectiveness of corticosteroids as stand-alone therapy. Two trials included only children, and because of the small number of participants in each RCT, there was high heterogeneity and inconsistent results in that group of patients. The meta-analysis was also underpowered to detect adverse effects; however, the short courses of corticosteroids are unlikely to be harmful.

 

Bottom Line:

In conjunction with antibiotic therapy, corticosteroids can reduce pain and decrease time to complete resolution of pain in patients with pharyngitis.

 

References

  1. Cline, D. (2013). Infections and disorders of the neck and upper airway. (3rd ed.) Tintinalli’s emergency medicine: Just the facts (pages 550-555). New York: McGraw-Hill.
  1. Korb, K., Scherer, M., & Chenot, J. F. (2010). Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: A systematic review. Annals of Family Medicine, 8(1), 58-63. http://www.annfammed.org/content/8/1/58.full.pdf+html
  1. Hayward, G., Thompson, M. J., Perera, R., Glasziou, P. P., Del Mar, C. B., & Heneghan, C. J. (2012). Corticosteroids as standalone or add-on treatment for sore throat. The Cochrane Database of Systematic Reviews, 10, CD008268. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008268.pub2/pdf

 

Continue Reading