ENT Emergencies: Final MB Revision Report (Prof. Afolabi)
Prof. Afolabi
31 Minutes
Final MB;BS
ENT Emergencies
1. Session Overview
This session was an open revision masterclass for final-year medical students. The lecturer invited students to specify areas requiring urgent clinical clarity; the class requested a systematic breakdown of emergencies in otorhinolaryngology.
Prof. Afolabi noted that the examination format has been updated: the number of questions drawn from each specialty posting is strictly limited, meaning each individual question carries substantial mark weight. The lecture was organized anatomically into emergencies of the ear, nose, and throat.
2. Ear Emergencies
2.1 Foreign Body in the External Auditory Canal
Animate Foreign Body (Live Insect): The mandatory first clinical action is to instill oil (e.g. olive oil) into the canal. This suffocates and stops insect movement, preventing ongoing mechanical irritation and patient panic.
Pinna Traction Differential: Inspect postauricular and anterior regions, then apply gentle traction to the pinna. Exquisite tenderness confirms otitis externa. In otitis media, traction causes no pain.
Otoscopy Technique: Inspect with a headlight first. Hold the otoscope in your right hand for the right ear, and left hand for the left ear. Identify the position of the object before advancing the speculum to avoid bumping inflamed canal walls and causing pain.
Inflamed Canal Dressing: Aural toileting followed by an aural wick impregnated with antibiotic and steroid drops (antibiotic for microbial clearance, steroid to reduce edema). Change daily or on alternate days according to discharge volume.
2.2 Acute Ear Trauma
Causes include slaps to the ear, sports impact, cotton bud insertion, and blast barotrauma. Pathology involves tympanic membrane perforation and ossicular dislocation.
Hearing Assessment: Rinne and Weber tuning fork tests at bedside. Formal testing requires pure tone audiometry for patients aged 5 and above, and free-field audiometry for children under 5.
2.3 CSF Otorrhoea Red Line
Following road traffic injuries or base-of-skull fractures, clear fluid may drain from the ear.
Strict Rule: Keep the ear sterile and dry. Insert zero instruments, wicks, or syringing fluids into the canal. Instrumentation introduces pathogens into subarachnoid CSF pathways, leading to fatal meningitis.
3. Nose Emergencies
3.1 Epistaxis Management
Classification: Anterior bleeding drips from the external nares. Posterior bleeding tracks down the oropharynx, presenting with coughing up or spitting blood.
Etiology: Local trauma, rhinitis, medications (anticoagulants), and hematological disorders. Hypertension does not cause epistaxis but exacerbates ongoing haemorrhage.
Stepwise Resuscitation: Compress anterior cartilaginous nares firmly (Trotter's method). Draw blood simultaneously for Full Blood Count (FBC) and Electrolytes/Urea (E/U). For persistent posterior bleeding unresponsive to anterior packs, insert a posterior pack using a Foley catheter inflated in the nasopharynx.
3.2 Nasal Foreign Body in Children
Diagnostic Maxim: Unilateral foul-smelling nasal discharge in a child is a retained foreign body until proven otherwise.
Immobilize the child securely, visualize via anterior rhinoscopy with a headlight, and advance a blunt right-angled hook or forceps beyond the object before pulling forward.
3.3 Button Batteries (Urgent)
Alkaline button batteries generate electrical currents, hydroxide ions, and liquefactive chemical necrosis within hours.
Requires immediate, atraumatic extraction to avoid permanent septal perforation, saddle nose deformity, and chondronecrosis.
4. Throat and Neck Emergencies
Stridor Anatomy & Timing
Audible turbulent airflow through a narrowed airway.
- Laryngeal level: Inspiratory stridor.
- Tracheobronchial level: Expiratory stridor.
- Intermittent cyanosis: Indicates critical airway obstruction requiring immediate intervention.
Peritonsillar Abscess (Quinsy)
Collection of pus in the potential peritonsillar space between tonsillar capsule and superior constrictor muscle.
- Clinical triad: Hot-potato speech, severe trismus, and uninhibited drooling.
- Oral finding: Medial displacement of the affected palatine tonsil and uvular deviation to the contralateral side.
Deep Neck Space Infections
Ludwig's angina, parapharyngeal and retropharyngeal collections secondary to odontogenic infections.
Presents with fever, wood-like brawny submandibular swelling, elevated tongue, and airway compromise. Manage with aggressive IV broad-spectrum antibiotics (metronidazole + third-gen cephalosporin), IV dexamethasone, and urgent surgical incision and drainage.
Cut Throat Injuries
Arising from assault or suicide attempts. Survivors present with gaping anterior neck lacerations.
Airway Priority: Secure an alternative airway via tracheostomy before induction of general anaesthesia. Place a size 20–22 nasogastric tube to stent pharyngeal mucosa and allow enteral feeding.
4.5 Aerodigestive Tract Foreign Bodies
Dentures, fish bones, safety pins, and impacted meat boluses commonly lodge at the cricopharyngeus (C6 level), where anatomical narrowing arrests transit.
5. Master Emergency Summary Table
| Emergency Presentation | Key Clinical Presentation | Definitive Action |
|---|---|---|
| Live Insect in Ear | Flapping noise, severe pain, otalgia | Instil olive oil, then otoscopy and extraction. |
| Tympanic Perforation | Cotton bud injury, slap, hearing drop | Otoscopy, Rinne/Weber, pure tone (≥5y) or free-field (<5y). |
| CSF Otorrhoea | Clear leakage post-cranial trauma | Keep sterile and dry; zero instrumentation. |
| Severe Epistaxis | Persistent posterior oropharyngeal bleeding | Nares pressure, FBC + E/U, posterior Foley catheter tamponade. |
| Nasal Foreign Body | Unilateral purulent foul discharge in child | Restrain child, pass hook beyond object; emergency extraction if battery. |
| Cut Throat | Open cervical wound, exposed airway | Emergency tracheostomy, surgical repair under GA, size 20–22 NG stent. |
| Throat Foreign Body | Dysphagia, drooling, impacted meat/denture | Soft tissue lateral neck X-ray, then rigid direct oesophagoscopy. |
6. Examination Guidance & Final Advice
Prof. Afolabi affirmed that students who were diligent during their ward rounds, clinics, and emergency duties have the necessary exposure to pass comfortably. The exam questions were compiled and submitted for final selection by the Head of Surgery.
Candidates are encouraged to rehearse the structured order: History → Examination → Investigations → Management → Follow-up, focusing primarily on prompt recognition and preventing secondary morbidity.