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Pain in the Neck!Pain in the Neck!
An EBM review of emergency An EBM review of emergency department ENTdepartment ENT
Petr Balcar FRCPCDec 15, 2011
OutlineOutlineReview best evidence in
management of ◦Epistaxis◦Fishbone FB◦Tonsillitis◦Post Tonsillectomy
Epistaxis QuestionsEpistaxis QuestionsDiscuss evidence for:
◦INR◦Cool compress◦Topical antibiotics◦Hemostatic agents◦Oral antibiotics in packing◦Safety of bilateral packing
Epistaxis: PearlsEpistaxis: PearlsSpeculum parallel to floor!Cauterize
◦Only controlled bleed◦Periphery inward◦1cm around bleeder◦Wipe excess AgNO3 off
Rapid Rhino ◦No saline/vaseline◦Impairs mesh thrombosis◦Recheck cuff 10-15min
Epistaxis: AnticoagulationEpistaxis: AnticoagulationNot routineWarfarin with therapeutic INR
◦25% annual rate◦Rare to need reversal
Discussion point:◦Do all need ENT FU?
Epistaxis: Cool CompressEpistaxis: Cool CompressBestBets review
◦3 small studies: 1. Sucking ice = nasal vasoconstriction 2. Neck ice packs = nasal
vasoconstriction 3. Forehead ice = 22/28 bleeds stopped
Summary:◦Scant evidence◦Benign intervention
Discussion point:◦Should we hand out ice at triage?◦Anyone want to do study?
Epistaxis: Topical Epistaxis: Topical AntibioticsAntibioticsMultiple pediatric studies
◦Intranasal antibiotic x 4wks = cautery◦No long term benefit◦Minimal sefx
Staph carriage in adults◦Walker and Baring 2009◦Small RTC n=49◦Nasal swabs ◦No difference in S. aureus carriage
~21%Conclusion
◦Consider in pediatrics
Epistaxis: Hemostasis Epistaxis: Hemostasis AgentsAgentsMultiple thrombogenic products
◦Quixil (fibrin glue spray) ◦Floseal (thromin gel)◦Surgicel◦Gelfoam◦Avitene◦Positive effect in small studies, few
RCTs◦Primarily developed for surgical use
Epistaxis: Fibrin GlueEpistaxis: Fibrin GlueVaiman 2002
◦RCT n 204◦Fibrin glue (Quixil) vs AgNO3 vs
Cautery vs foam packing◦~93% immediate cessation◦Mean 2.5 min◦Fewer mucosal sefx
Epistaxis and Tranexamic Epistaxis and Tranexamic AcidAcidLysine derivative Antifibrinolytic
◦Prevents plasmin to plasminogenHereditary hemorrhagic
telangectasia◦Case studies◦Benefit of intranasal spray
Cochrane study under way
Epistaxis: Antibiotics with Epistaxis: Antibiotics with PackingPackingPostoperative rates 16 : 100,000PO antibiotics do not reduce
nasal staphNo good studies: very rare eventMultiple side-effects of antibioticsMost ENTs do itHigher risk elderly,
immunocompromised, prolonged pack
Discussion Point:◦Do you start antibiotics?
Epistaxis: Bilateral Epistaxis: Bilateral Packing Packing Hollis 2011
◦Anatomical model◦Bilateral pack = decrease in septal
deflectionHady 1983
◦Healthy volunteers packing◦ABG at 24 hrs◦Increased CO2, decreased PO2, pH
equalLoftus 1994
◦19 pts, posterior pack◦Pulse oximetry monitor x 1200hrs◦No desats
Epistaxis: Bilateral Epistaxis: Bilateral PackingPackingHistorical cases with bad outcomes
◦ Posterior packing patients died◦ Hypothesized nasopulmonary reflex
No current evidence of significant morbidity/mortality with bilateral packing
Posterior bleed patients need admit Anterior bleed with bilateral pack
◦ Consider DC in healthy patients, admit in frail/elderly
Discussion point:◦ Who does bilateral packing?◦ Do you admit them?
Fish Bone: QuestionsFish Bone: QuestionsHow useful is plain X-ray?How useful are symptoms?Do all need scope?
Fish Bone: Are Bones Fish Bone: Are Bones Opaque?Opaque?Lue 2000
◦10 fish bones in cadaver head/neck◦Blinded radiologists◦Plain Xray 39% sensitive◦CT 9/10 found◦Cooking did not change opacity◦Variability by species, orientation
Hone1995◦10 fish bones in cadaver neck◦9/10 seen by both rads
Fish Bone: Clinical Xray Fish Bone: Clinical Xray UtilityUtilitySeveral clinical imaging studies
◦Sensitivity ~30%◦Specificity ~88%
Ngan 1990◦Prospective n=358◦Clinical symptoms not reliable for FB◦Clinical symptoms did localize FB if
present◦117 bones found
21 direct removal 82 endoscopic removal
Fish Bone: Clinical Fish Bone: Clinical RelevanceRelevanceImpacted oropharyngeal bone
location Tonsils, base of tongue, vallecula
Impacted bones migrate! Many case reports of significant pathology Abscess, vascular
Should not be ignored!Discussion point:
◦Do you xray all patients?◦Do you get ENT/GI FU for all patients?
Pharyngitis: QuestionsPharyngitis: QuestionsReview pathogensBest evidence:
◦When to treat ◦Which antibiotics and how long◦What to do if treatment fails◦Analgesia
Pharyngitis: Bug PearlsPharyngitis: Bug Pearls Usually viral
◦ Consider EBV
GAS◦ Very common
◦ Serious Complications
◦ GBS/GCS minimal complications
HIV in at risk population◦ Early diagnosis/treatment
Mycoplasma / Chlamydia◦ Peds RCT n=133
◦ >30% carriage, not improved by Azithro
Ghonococcal ◦ 5-15% carriage in MSM
◦ Rare symtomatic, Rc Ceftriaxone
Diptheria◦ Un-immunized, endemic travel
Pharyngitis: Why Treat Pharyngitis: Why Treat GAS?GAS?Prevent complications
◦Suppurative◦Rheumatic Fever
Up to 9 days post ssx◦Scarlet Fever
Reduce symptoms◦If within 48hrs
Reduce transmission◦~35% close contacts◦Within 24hr, 80% swab neg
Pharyngitis: AntibioticsPharyngitis: AntibioticsPenicillin
◦100% susceptibility◦Pen V PO x 10days◦Pen G IM lasts 3-4 weeks!
Amoxicillin◦100% susceptibility◦Tastes better (yum)◦AOM 15%
Clindamycin◦93% susceptibility ◦Better staph/anaerobe
Pharyngitis: AntibioticsPharyngitis: Antibiotics Cephalosporins
◦ 100% susceptibility
◦ Casey et al 2004
Meta analysis: pen vs cephalosporin
<18yrs, n=7135
Clinical and culture cure
Both superior in cephalosporins
Cost more, increased use in community
Macrolides
◦ 93% susceptibility
◦ Meta analysis shows improved compliance
Pharyngitis: Why Pharyngitis: Why Antibiotics FailAntibiotics FailConfirmed GAS
◦ Chronic Carrier (up to 20% peds)
◦ Poor compliance
◦ Re-infection
Pet, toothbrush, dentures
◦ Other beta-lactamase flora
◦ Poor antibiotic penetration of tissue
◦ Resistant strain (No pen resist strain
Identified!)
◦ Treat too early, reduced immune responseNon GASSuppurative complication
Pharyngitis: When Pharyngitis: When Treatment FailsTreatment FailsNo Specific EvidenceScreen for atypical etiologyLook for abscessRepeat culture GAS +
◦Consider other PO Abx +/- IM PenRecurrent episodes
◦Consider testing family and treat all +ve
◦Consider chronic carrier with Viral◦6/year = tonsillectomy
Pharyngitis: Evidence for Pharyngitis: Evidence for SteroidsSteroidsAll ENT’s do it!Cochrane study in progressMultiple small studies
◦Pediatrics 3 studies Oral Dexamethason
◦Adults 7 studies IM or PO steroid
◦Overall ~ 5-6hr quicker pain relief◦No Early difference in Sefx
Pharyngitis: SummaryPharyngitis: SummaryConsider atypical causesHigh risk: tearly + swabAntibiotics
◦Penicillin still 1st choice◦Cephalosporins excellent◦Amoxil peds
Failure re-testAnalgesia
◦Topical lozenges◦Steroids
Peritonsillar Abscess: Peritonsillar Abscess: QuestionsQuestionsUtility of USBest treatment options
Peritonsillar Abscess: US Peritonsillar Abscess: US ImagingImagingRelatively new Several small studiesExcellent for Abscess locations
◦Intraoral = 95% sensitive◦Transcutaneous = 80% sensitive
Peritonsillar Abscess: US Peritonsillar Abscess: US DrainageDrainageCostantino 2010
◦RCT n=23◦ED physician, US vs blind drainage◦Diagnosis 100% vs 63%◦Aspiration 100% vs 42%◦ENT Referal 8% vs 55%
Peritonsillar Abscess: Peritonsillar Abscess: TreatmentTreatmentSeveral poor studiesOverall I&D = Needle
◦ ~90% success rateConsider primary tonsillectomyAntibiotics
◦Usually polymicrobial◦IV Pen/Clinda◦PO Pen/Clinda/Amox-clav
Steroids reduce morbidity
Peritonsillar Abscess: Peritonsillar Abscess: SummarySummaryNeedle okayUS guided probably bestIv steroid dose helpsDiscussion point:
◦Lets buy an oral probe!
Post Tonsillectomy: Post Tonsillectomy: QuestionsQuestionsIndicationsHow much bleeding is
concerning?Analgesic options
Post Tonsillectomy: Post Tonsillectomy: BleedingBleedingSignificant hemorrhage 1-3%1:40,000 fatal95% secondary (>24 hr) Up to 39 daysBlood = ENTConsider admitActive bleed
◦Pressure◦Epi◦+/-Thrombin
Post Tonsillectomy: Post Tonsillectomy: AnalgesiaAnalgesiaExpected pain pattern:
◦Improve over 3-5 days◦Then increases for 1-2 days◦Resolves
Steroids given periopNSAIDS?
Post Tonsillectomy: Post Tonsillectomy: NSAIDSNSAIDSSurgeon will not be pleased!Several RCTs, 2 good reviews
◦Marret 2003 N = 262 Need for OR
NNH 29
◦Moinche 2003 N = 970 Need for OR
NNH 60
Reduction in N/V vs opioid NNT 9
Post Tonsillectomy: Post Tonsillectomy: SummarySummaryDelayed pain presentationAny bleed need ENT FUNo NSAIDs
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