Key Facts

ENT emergencies frequently present to the emergency department and range from common conditions (epistaxis, foreign bodies) to life-threatening airway emergencies (epiglottitis, Ludwig's angina). The key priority is always airway assessment.

Epidemiology

Epistaxis accounts for approximately 1 in 200 ED attendances. Peritonsillar abscess is the most common deep neck space infection (~30 per 100,000/year). Epiglottitis has become rare in children following Hib vaccination but is increasing in adults. Foreign body ingestion/aspiration is most common in children aged 1-3 years.

Aetiology

• Epistaxis: Idiopathic (most common), trauma (nose picking), anticoagulants, hypertension, hereditary haemorrhagic telangiectasia (HHT), nasal tumour
• Peritonsillar abscess: Complication of tonsillitis; Group A streptococcus, anaerobes
• Epiglottitis: H. influenzae type b (Hib) — rare post-vaccination; Group A strep, S. aureus in adults
• Foreign bodies: Coins, small toys (ingestion); peanuts, small objects (aspiration)

Pathophysiology

Epistaxis from Little's area involves the anastomotic network of the anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries. Posterior bleeds from the sphenopalatine artery are higher volume and harder to control. Peritonsillar abscess forms in the peritonsillar space between the tonsil capsule and pharyngeal constrictor. Epiglottitis involves bacterial supraglottitis causing rapid oedema and potential airway obstruction.

Epistaxis

• Anterior: Visible bleeding from nostril, often unilateral
• Posterior: Bleeding into pharynx, bilateral, often heavier and in older patients
• Recurrent epistaxis — consider coagulopathy, HHT, nasal pathology

Peritonsillar Abscess

• Severe sore throat (usually unilateral), odynophagia, trismus
• 'Hot potato' voice (muffled), drooling
• Unilateral tonsillar bulge with uvular deviation to opposite side
• Fever, tender cervical lymphadenopathy

Epiglottitis

• Rapid onset sore throat, stridor, drooling
• Tripod position (sitting forward, chin up)
• Toxic, febrile, distressed
• In children: Do NOT examine throat — risk of complete airway obstruction

Red Flags

• Stridor — airway emergency
• Massive epistaxis with haemodynamic instability — posterior bleed; activate ENT
• Button battery in oesophagus — emergency endoscopic removal (perforation in 2h)
• Bilateral submandibular swelling (Ludwig's angina) — impending airway obstruction
• Suspected inhalation foreign body — rigid bronchoscopy

Bedside

• Airway assessment: Priority in all ENT emergencies
• Anterior rhinoscopy: Identify bleeding source (epistaxis)
• Oropharyngeal examination: Tonsillar swelling, uvular deviation (quinsy)
• Flexible nasendoscopy: Visualise larynx if safe (epiglottitis — only by experienced practitioner)

Bloods

• FBC, coagulation, G&S: For significant epistaxis
• Blood cultures: If sepsis suspected (epiglottitis, deep neck space infection)
• CRP: Infection marker

Imaging

• Lateral soft tissue neck X-ray: Epiglottitis (thumb sign), retropharyngeal abscess
• CT neck with contrast: Deep neck space infections (peritonsillar, retropharyngeal, parapharyngeal, Ludwig's)
• CXR: Foreign body aspiration (hyperinflation, atelectasis) — often normal; expiratory films may help
• X-ray (AP neck/chest): Ingested foreign body — identify radio-opaque objects; button batteries appear as double-ring sign

Special Tests

• Rigid bronchoscopy: For confirmed or suspected inhaled foreign body
• Nasal endoscopy: After posterior packing for definitive assessment

Epistaxis Management (Stepwise)

1. First aid: Sit forward, pinch soft nose 15-20 min, ice to bridge of nose
2. Chemical cautery: Silver nitrate stick to visible bleeding point (one side only per session)
3. Anterior nasal packing: Merocel or Rapid Rhino pack; leave 24-48h
4. Posterior packing: Foley catheter or posterior balloon pack; admit; ENT involvement
5. Surgical: Sphenopalatine artery ligation or IR embolisation for refractory bleeding

Peritonsillar Abscess

• Needle aspiration (first-line) or incision and drainage (if aspiration fails)
• IV antibiotics: Benzylpenicillin 1.2g IV QDS + metronidazole 500mg IV TDS
• Analgesia and IV fluids
• Interval tonsillectomy if recurrent

Epiglottitis

• Do NOT distress patient — maintain calm environment
• Senior anaesthetist for controlled intubation (fibre-optic or gas induction)
• IV ceftriaxone 2g (or co-amoxiclav + dexamethasone)
• IV dexamethasone 0.6mg/kg: Reduces oedema

Foreign Body

• Oesophageal button battery: Emergency endoscopic removal (<2h)
• Oesophageal coin: Can observe 24h if asymptomatic; remove if still present
• Inhaled FB: Rigid bronchoscopy under GA
• Nasal FB: Attempt removal with Jobson-Horne probe; mother's kiss technique in children

Referral Criteria

• Posterior epistaxis uncontrolled by anterior packing — ENT emergency
• Peritonsillar abscess — ENT for drainage
• Epiglottitis — anaesthetics + ENT emergency
• Inhaled/ingested foreign body — ENT/paediatric surgery

• Epistaxis: >90% controlled with first aid and cautery; ~5% require packing; <1% require surgery
• Peritonsillar abscess: Excellent with drainage; ~10-15% recurrence; interval tonsillectomy reduces recurrence
• Epiglottitis: Mortality <1% with appropriate airway management; was ~6% before Hib vaccination
• Button battery ingestion: If oesophageal and not removed within 2h — significant morbidity (perforation, mediastinitis, aorto-oesophageal fistula)

Epistaxis Management Ladder

Button Battery Ingestion — Emergency Protocol