ENT: #4 Emergenices

• Airway: Stridor and Upper Airway Obstruction | Epiglottitis and Supraglottitis | Angioedema | Tracheostomy Emergencies | Laryngectomy — Neck Breathers
• Bleeding: Epistaxis | Post-tonsillectomy Bleeding
• Throat and neck infections: Quinsy | Deep Neck Space Infection | Lemierre Syndrome
• Ear and nose: Sudden Sensorineural Hearing Loss | Facial Palsy — the ENT View | Acute Mastoiditis | Necrotising Otitis Externa | Complications of Sinusitis | Ear Trauma | Nasal Injury and Septal Haematoma
• Foreign bodies: Ear and Nose Foreign Bodies | Swallowed Foreign Bodies and Food Bolus
• Revision: Drug Reference Table | Spot the Emergency | Exam-style Scenarios | Key Points | Guidelines and Further Reading

👂 ENT emergencies are mostly about the airway and bleeding. A patient with stridor, drooling or a muffled "hot potato" voice can obstruct suddenly, so don't lie them flat, don't examine the throat with a tongue depressor, and get senior anaesthetic and ENT help early. Nosebleeds are common and usually simple, but some are life-threatening. Other emergencies are easy to miss: sudden deafness, a button battery in the nose or throat, and necrotising otitis externa.
Your four questions for every patient: Is the airway safe — stridor, drooling, voice change, can they swallow saliva? Is there active bleeding, and are they on anticoagulants? Is there sepsis or a spreading neck infection? Do they have a tracheostomy or laryngectomy?

Stridor and Upper Airway Obstruction

• Stridor — a harsh, high-pitched noise from turbulent airflow through a narrowed upper airway.
  • Inspiratory — at or above the larynx (supraglottic, vocal cords).
  • Biphasic — at the cords or upper trachea.
  • Expiratory — lower trachea or bronchi.
• Danger signs:
  • Drooling, can't swallow saliva.
  • Muffled ("hot potato") voice.
  • Sitting forward, tripod position; refusing to lie down.
  • Use of accessory muscles, agitation, then exhaustion and drowsiness (late).
  • Falling oxygen saturation (late sign).
• Causes in adults:
  • Infection — supraglottitis, deep neck abscess, Ludwig's angina.
  • Angioedema and anaphylaxis.
  • Laryngeal or tracheal tumours (often gradual, in smokers).
  • Bilateral vocal cord palsy (after thyroid surgery).
  • Foreign body; trauma; burns or smoke inhalation.
  • Thyroid enlargement (retrosternal goitre); haematoma after neck surgery.
• Causes in children: Croup (commonest), epiglottitis (rare since Hib vaccine), inhaled foreign body, bacterial tracheitis, anaphylaxis.
• Initial management:
  • Call for help early — senior anaesthetist and ENT surgeon; plan for a difficult airway.
  • Keep the patient sitting up and calm; don't lie them flat.
  • High-flow oxygen.
  • Nebulised adrenaline (1 mg of 1:1,000 = 1 mL, made up to 5 mL with saline) — temporary relief.
  • IV dexamethasone (e.g. 6.6–8 mg) — reduces swelling.
  • Heliox — eases airflow (buys time).
  • Avoid sedation.
  • Definitive airway in theatre — awake fibreoptic intubation or awake tracheostomy under local anaesthetic; front-of-neck access (cricothyroidotomy) if "can't intubate, can't oxygenate".
• Neck haematoma after thyroid or neck surgery — remove the skin and muscle sutures at the bedside ("SCOOP" — skin exposure, cut sutures, open skin, open muscles, pack) if the airway is compromised, then theatre.

⚠️ Safety Pearl: In suspected supraglottitis or deep neck infection, don't put a tongue depressor in the mouth, don't lie the patient flat, and don't send them alone to CT — any of these can trigger complete obstruction.

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Epiglottitis and Supraglottitis

• What it is: Infection and swelling of the epiglottis and surrounding tissue above the vocal cords. Now more common in adults than children (thanks to Hib vaccination).
• Organisms: Haemophilus influenzae type b (unvaccinated), Streptococcus, Staphylococcus.
• Features:
  • Severe sore throat and painful swallowing out of proportion to what you see in the mouth (throat may look normal).
  • Drooling; muffled voice.
  • Fever; looks unwell.
  • Stridor (late in adults).
  • Tenderness over the hyoid.
• Diagnosis:
  • Flexible nasendoscopy by ENT (in a safe place, with airway support ready) — swollen, red epiglottis.
  • Lateral neck X-ray — "thumb sign" (not needed if endoscopy is available).
• Management:
  • Airway first — senior anaesthetic and ENT; sit up; oxygen; nebulised adrenaline.
  • IV antibiotics — e.g. ceftriaxone (with metronidazole if abscess suspected), per local policy.
  • IV dexamethasone.
  • Admit to HDU or ICU for close airway monitoring.
  • Children — don't examine the throat, keep the child with the parent, don't distress them; go straight to theatre for an airway under gas induction.
  • Close contacts of Hib cases may need rifampicin prophylaxis.

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Angioedema

• Swelling of the lips, tongue, floor of mouth and larynx — can block the airway.
• Types:
  • Histamine-mediated (allergic) — with urticaria, itching, wheeze; anaphylaxis. Treat with IM adrenaline 0.5 mg (adults), antihistamine, steroids.
  • Bradykinin-mediated — no urticaria or itch; doesn't respond well to adrenaline or antihistamines:
    • ACE inhibitor angioedema — can happen years after starting; tongue and lips; more common in people of Black African or Caribbean ancestry. Stop the ACE inhibitor permanently (and record it).
    • Hereditary angioedema (C1 esterase inhibitor deficiency) — recurrent swellings, abdominal pain attacks; low C4. Treat with C1 inhibitor concentrate or icatibant.
    • Gliptins, sacubitril/valsartan, alteplase (stroke thrombolysis).
• Management:
  • Assess the airway — nasendoscopy if voice change, drooling or stridor.
  • Give adrenaline if any doubt about anaphylaxis.
  • Early anaesthetic and ENT involvement — awake fibreoptic intubation or tracheostomy if swelling progresses.
  • Observe for several hours (ACE inhibitor angioedema can worsen over 24–48 hours).

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Tracheostomy Emergencies

• Tracheostomy — a tube placed into the trachea through the front of the neck. The upper airway is still connected, so the patient can usually be oxygenated from the mouth too.
• Bedside essentials — spare tubes (same size and one smaller), tracheal dilators, suction, oxygen, and a bedhead sign (NTSP — National Tracheostomy Safety Project) showing the airway type.
• Emergencies:
  • Blocked tube (secretions) — the commonest.
  • Displaced tube — especially in the first week (before the track forms).
  • Bleeding — small (granulation tissue) or catastrophic (tracheo-innominate artery fistula — often preceded by a "herald" bleed).
• NTSP emergency algorithm (breathing difficulty):
  • Call for help (airway expert).
  • Look, listen and feel at the mouth and the tracheostomy.
  • Apply high-flow oxygen to both the face and the tracheostomy.
  • Remove any speaking valve, cap, or inner tube (clean or replace it).
  • Pass a suction catheter — if it passes easily, the tube is patent; suction secretions.
  • If not — deflate the cuff.
  • Still not breathing well — remove the tracheostomy tube.
  • Then oxygenate via the mouth and nose (cover the stoma) or via the stoma (small mask or paediatric face mask); intubate orally or re-insert a tube through the stoma (experts).
  • If not breathing — start CPR.

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Laryngectomy — Neck Breathers

• Total laryngectomy (usually for laryngeal cancer) — the larynx is removed and the trachea is brought out as a permanent stoma in the neck. There is no connection between the mouth and the lungs.
• What this means:
  • Oxygen must be given via the neck stoma, not the face.
  • Oral intubation is impossible — intubate through the stoma.
  • Bag-valve-mask ventilation via the stoma (paediatric mask).
  • Patients may have a voice prosthesis (valve between trachea and oesophagus) — don't remove it; if it falls out, block the hole to stop aspiration.
• Emergency (NTSP laryngectomy algorithm):
  • Call for help; apply oxygen to the stoma.
  • Remove any stoma cover or device.
  • Pass a suction catheter; remove crusts (common — humidify).
  • If not breathing — CPR, ventilate via the stoma.
• Look for the bedhead sign and ask — "neck breathers" carry cards and may wear stoma covers.

💡 Clinical Pearl: Before putting an oxygen mask on the face of a patient with a hole in their neck, find out whether they have a tracheostomy (upper airway connected) or a laryngectomy (no connection) — it changes everything about airway management.

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Epistaxis

• Anterior bleeds (about 90%) — from Little's area (Kiesselbach's plexus) on the front of the septum; usually children and young adults; usually easy to stop.
• Posterior bleeds — from the sphenopalatine artery branches; older people, hypertension, anticoagulants; heavier, both nostrils, blood down the throat; harder to control.
• Causes:
  • Local — nose picking, dry air, trauma, infection, nasal sprays (steroids), cocaine, tumours (rare — unilateral, recurrent, with obstruction or discharge).
  • Systemic — anticoagulants and antiplatelets, bleeding disorders, liver disease, kidney failure, alcohol, hereditary haemorrhagic telangiectasia (HHT — recurrent nosebleeds, telangiectasia on lips and fingers, family history).
  • Hypertension — associated with severity, but rarely the cause.
• Management — step by step:
  • ABC; assess blood loss (pulse, BP); IV access, FBC, clotting, group and save if heavy; PPE (spitting blood).
  • First aid — sit up, lean forward, mouth open; pinch the soft, lower part of the nose firmly for 10–20 minutes without letting go; spit out blood; ice on the bridge or in the mouth.
  • Look with a headlight after clearing clots; topical vasoconstrictor and local anaesthetic (e.g. co-phenylcaine) on cotton wool.
  • Cautery — silver nitrate to a visible bleeding point (one side of the septum only, to avoid perforation).
  • Nasal packing if bleeding continues — nasal tampon or inflatable pack (e.g. Rapid Rhino); admit under ENT.
  • Tranexamic acid — topical (on a pledget) or IV/oral; useful in ongoing bleeding.
  • Posterior bleeding — posterior or double-balloon packing; may need endoscopic sphenopalatine artery ligation or embolisation.
  • Anticoagulants — check INR; discuss holding or reversing with the haematology team, balancing clot risk.
• After a nosebleed:
  • Naseptin cream (chlorhexidine and neomycin) twice daily for 2 weeks — reduces crusting and recurrence. Contains peanut oil — avoid in peanut or soya allergy (mupirocin as an alternative).
  • Avoid nose blowing, picking, heavy lifting, hot drinks and alcohol for a few days.
• Refer if: recurrent bleeds despite cautery, unilateral bleeding with obstruction or discharge (exclude tumour — including juvenile angiofibroma in adolescent boys), suspected HHT.

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Post-tonsillectomy Bleeding

• Primary bleed — within 24 hours of surgery; usually back to theatre.
• Secondary bleed — typically 5–10 days after surgery, often linked to infection as the scab separates.
• Why it's dangerous: Blood is swallowed (hidden loss, especially in children — vomiting blood, frequent swallowing, tachycardia), and can block the airway.
• Management:
  • Any bleed after tonsillectomy — go to hospital.
  • Sit up, lean forward, spit out blood; IV access; FBC, group and save/crossmatch.
  • Hydrogen peroxide or adrenaline gargles (local protocol) for minor oozing.
  • Tranexamic acid IV or oral.
  • IV antibiotics (infection often triggers secondary bleeding).
  • Return to theatre for heavy or ongoing bleeding — warn the anaesthetist about a full stomach of blood.

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Quinsy

• What it is: A peritonsillar abscess — a complication of tonsillitis, usually in young adults.
• Features:
  • Severe, one-sided sore throat, getting worse after a few days of tonsillitis.
  • Trismus (can't open the mouth fully).
  • Muffled "hot potato" voice.
  • Drooling; painful swallowing; ear pain.
  • Fever; bad breath.
  • Uvula pushed to the opposite side; bulging soft palate above the tonsil.
• Management:
  • Same-day ENT referral.
  • Needle aspiration or incision and drainage under local anaesthetic.
  • IV antibiotics — e.g. benzylpenicillin with metronidazole (or co-amoxiclav), switching to oral.
  • Steroids (single dose of dexamethasone) can reduce pain and swelling.
  • Analgesia; IV fluids if not drinking.
  • Tonsillectomy may be offered after recurrent quinsy.

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Deep Neck Space Infection

• Parapharyngeal and retropharyngeal abscess:
  • Spread from tonsils, teeth, or lymph nodes (retropharyngeal is more common in young children).
  • Fever, neck pain and stiffness, reluctance to move the neck, painful swallowing, drooling, trismus, stridor.
  • Swelling of the side of the neck or the back wall of the throat.
  • CT neck with contrast (only if the airway is safe).
  • IV antibiotics and surgical drainage.
  • Can spread down into the chest (mediastinitis) — high mortality.
• Ludwig's angina:
  • Rapidly spreading cellulitis of the floor of the mouth (submandibular space), usually from an infected lower molar tooth.
  • Raised, firm floor of mouth, tongue pushed up and back, "woody" neck swelling, drooling, can't swallow.
  • Airway obstruction can be sudden.
  • Airway management (often awake fibreoptic intubation or tracheostomy), IV antibiotics (e.g. co-amoxiclav or benzylpenicillin with metronidazole), dental extraction and drainage.
  • Risk factors — diabetes, poor dental hygiene, immunosuppression.
• Necrotising fasciitis of the neck — rare; severe pain, crepitus, systemic toxicity; emergency debridement.

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Lemierre Syndrome

• What it is: Septic thrombophlebitis of the internal jugular vein after a sore throat, usually caused by Fusobacterium necrophorum.
• Who: Previously healthy teenagers and young adults.
• Features:
  • Sore throat that seems to improve, then high fever, rigors.
  • Neck pain and swelling along the sternocleidomastoid.
  • Septic emboli to the lungs (cavitating nodules, pleuritic pain, breathlessness), joints, liver.
• Diagnosis: Blood cultures (anaerobic organism); CT neck with contrast or ultrasound showing jugular vein thrombosis; CT chest.
• Treatment: Prolonged IV antibiotics (e.g. penicillin or ceftriaxone with metronidazole, for several weeks); drain abscesses; anticoagulation sometimes used (specialist decision).

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Sudden Sensorineural Hearing Loss

• What it is: Sudden inner ear (or nerve) hearing loss, usually in one ear, over up to 3 days. An emergency — treatment works best when given early.
• Features:
  • Sudden muffled or lost hearing in one ear, often noticed on waking.
  • Tinnitus, ear fullness; sometimes vertigo.
  • Ear looks normal on otoscopy — easily mistaken for wax or "blocked ear".
• Tuning forks (512 Hz):
  • Weber — sound heard in the good ear (in conductive loss it goes to the bad ear).
  • Rinne — positive (air better than bone) in the affected ear.
• Causes:
  • Idiopathic (most) — possibly viral or vascular.
  • Vestibular schwannoma (acoustic neuroma) — in a small minority.
  • Stroke (AICA territory — with vertigo and other neurological signs).
  • Autoimmune disease; syphilis; Ménière's disease; trauma or barotrauma; ototoxic drugs.
• Referral (NICE NG98):
  • Hearing loss that developed suddenly (over 3 days or less) within the past 30 days — refer immediately (to be seen within 24 hours) to ENT or emergency services.
  • Hearing loss that worsened over 4–90 days, or sudden loss more than 30 days ago — urgent referral (within 2 weeks).
  • With neurological signs — immediate (emergency) referral.
• Treatment (ENT):
  • Oral steroids — e.g. prednisolone 1 mg/kg/day (maximum 60 mg) for about 7 days then taper — ideally within 14 days of onset.
  • Intratympanic steroid injections — if oral steroids aren't suitable or as salvage.
  • Audiogram to confirm and monitor.
  • MRI internal auditory meatus to exclude vestibular schwannoma.
• Prognosis: About a third to two-thirds recover some hearing; worse with severe loss, vertigo and older age.

⚠️ Safety Pearl: A patient with sudden one-sided "blocked ear" and a normal-looking ear drum should be treated as sudden sensorineural hearing loss until proven otherwise — do a Weber test and refer the same day. Don't send them away with wax drops.

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Facial Palsy — the ENT View

• Lower motor neuron (LMN) facial palsy affects the whole side of the face, including the forehead. An upper motor neuron lesion (stroke) spares the forehead.
• Bell's palsy — the commonest cause; sudden LMN palsy with no other cause. Prednisolone within 72 hours (e.g. 50 mg daily for 10 days, or 60 mg for 5 days then taper); eye protection. See the Neuromuscular Disease chapter.
• ENT causes to exclude — look in the ear and feel the parotid:
  • Ramsay Hunt syndrome (herpes zoster oticus) — vesicles in the ear canal or on the palate, severe ear pain, facial palsy, often hearing loss and vertigo. Worse prognosis than Bell's. Treat with prednisolone plus valaciclovir or aciclovir within 72 hours.
  • Acute otitis media (especially children) or cholesteatoma (chronic smelly discharge).
  • Necrotising otitis externa (older diabetics).
  • Parotid tumour — a parotid lump with facial weakness suggests cancer; gradual onset or recurrent palsy needs imaging.
  • Temporal bone fracture.
  • Lyme disease (can be bilateral), sarcoidosis, Guillain–Barré (bilateral), HIV.
• Eye care — the eye can't close: lubricant drops by day, ointment at night, tape the lid closed at night; urgent eye review if painful or red.
• Refer if no recovery after 3 weeks, recurrent palsy, gradual onset, or other cranial nerve involvement.

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Acute Mastoiditis

• What it is: Spread of middle ear infection into the mastoid air cells — mostly in children.
• Features:
  • Recent or current otitis media.
  • Swelling, redness and tenderness behind the ear; the ear is pushed forward and outwards.
  • Fever; ear pain; discharge.
• Management:
  • Same-day admission under ENT.
  • IV antibiotics (e.g. ceftriaxone, or co-amoxiclav).
  • CT if not improving or complications are suspected.
  • Surgery — grommet, drainage of subperiosteal abscess, cortical mastoidectomy.
• Complications: Subperiosteal abscess, meningitis, brain abscess, sigmoid sinus thrombosis, facial palsy, labyrinthitis.

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Necrotising Otitis Externa

• What it is: A spreading infection of the ear canal into the skull base bone (osteomyelitis). Previously called "malignant" otitis externa.
• Who: Older people with diabetes (or immunosuppression). Usually Pseudomonas aeruginosa.
• Features:
  • Severe, persistent ear pain (worse at night), out of proportion to findings.
  • Discharge; granulation tissue on the floor of the ear canal.
  • Not responding to standard ear drops.
  • Cranial nerve palsies — facial (VII) first, then IX, X, XI, XII in advanced disease.
  • Headache; may have no fever.
• Tests: Swab; CRP and ESR (useful for monitoring); CT and MRI of the skull base; biopsy to exclude cancer.
• Treatment:
  • Prolonged antipseudomonal antibiotics — IV (e.g. ceftazidime, piperacillin–tazobactam) then oral ciprofloxacin, often for 6 weeks or more.
  • Tight diabetes control.
  • Ear cleaning (microsuction); topical antipseudomonal drops.
  • Monitor with symptoms, CRP and imaging.

💡 Clinical Pearl: An older person with diabetes and an "ear infection" that keeps hurting despite drops has necrotising otitis externa until proven otherwise — look for granulation tissue and check the facial nerve.

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Complications of Sinusitis

• Orbital complications (the commonest, especially children) — preseptal and orbital cellulitis, subperiosteal abscess (see the Red Eye and Eye Emergencies chapter).
• Intracranial complications:
  • Meningitis.
  • Subdural empyema and epidural abscess.
  • Brain abscess (frontal lobe).
  • Cavernous sinus thrombosis — both eyes affected, cranial nerve palsies (III, IV, V1, V2, VI), proptosis, sepsis.
• Pott's puffy tumour — frontal bone osteomyelitis with a soft swelling on the forehead (teenagers).
• Red flags in sinusitis (refer immediately):
  • Swelling or redness around the eye; displaced eye; double vision; reduced vision.
  • Severe frontal headache; forehead swelling.
  • Neurological signs; meningism; reduced consciousness.
  • Sepsis.
• Management: IV antibiotics (e.g. ceftriaxone with metronidazole); CT with contrast (orbits, sinuses, brain); MRI for intracranial spread; ENT, ophthalmology and neurosurgery; surgical drainage.
• Invasive fungal sinusitis (mucormycosis) — in poorly controlled diabetes (DKA) or neutropenia: black necrotic tissue in the nose or palate, facial pain, rapid spread — emergency surgery and antifungals (amphotericin).

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Ear Trauma

• Auricular (pinna) haematoma:
  • Blood collects between the cartilage and its covering after a blow (rugby, boxing).
  • Drain within 24–48 hours (needle aspiration or incision) and apply a pressure dressing — otherwise the cartilage dies and a "cauliflower ear" forms.
• Pinna lacerations — close skin over exposed cartilage; antibiotics (covering Pseudomonas) for cartilage involvement or bites.
• Perforated eardrum:
  • From a slap, explosion, cotton bud, barotrauma or infection.
  • Pain, bleeding, hearing loss.
  • Keep the ear dry; most heal within 6–8 weeks; review hearing.
  • Urgent ENT if vertigo or sensorineural loss (inner ear damage) or facial palsy.
• Temporal bone fracture (head injury):
  • Bleeding from the ear, Battle's sign (bruising behind the ear), CSF leak (clear fluid from ear or nose), haemotympanum (blood behind the drum).
  • Hearing loss, vertigo, facial palsy (immediate onset — may need surgery).
  • CT head and temporal bones; neurosurgery and ENT.
• Barotrauma — flying or diving: pain, fullness, hearing loss. Divers with vertigo or sensorineural loss after a dive may have inner ear barotrauma or decompression illness — urgent specialist advice.

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Nasal Injury and Septal Haematoma

• Nasal fracture:
  • Swelling, bruising, deformity, nosebleed.
  • X-rays are not needed for an isolated nasal fracture.
  • Check for septal haematoma, CSF leak, other facial fractures, eye injury and head injury.
  • Review in ENT clinic at 5–7 days, once swelling has settled; manipulation under anaesthetic within about 2–3 weeks if the nose is deformed.
• Septal haematoma:
  • Blood collects under the lining of the septum — soft, boggy, red or purple swelling blocking one or both nostrils.
  • Must be drained the same day — otherwise infection (septal abscess) and cartilage death cause a saddle-nose deformity.
  • Children — consider non-accidental injury.
• CSF rhinorrhoea — clear watery discharge after trauma (or spontaneously); test for beta-2 transferrin; meningitis risk; neurosurgery.
• Septal perforation — from cocaine, previous surgery, picking, GPA; crusting, whistling, nosebleeds.

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Ear and Nose Foreign Bodies

• Mostly children — beads, toys, food, paper, batteries.
• Nose:
  • Unilateral, smelly nasal discharge in a child = foreign body until proven otherwise.
  • Parent's kiss — the parent blocks the other nostril and blows into the child's mouth.
  • Removal with a hook or forceps in a cooperative child; otherwise ENT (sometimes general anaesthetic).
  • Risk of inhalation into the airway.
• Ear:
  • Remove under direct vision (microsuction, hook, forceps) — only one or two attempts in the ED, to avoid damaging the canal or drum.
  • Live insects — kill first with olive oil or lidocaine, then remove.
  • Don't syringe vegetable matter (it swells).
• Button batteries and magnets — emergencies:
  • Button batteries in the nose or ear cause tissue burns within hours (septal perforation, canal damage) — remove immediately.
  • Don't use ear drops with a battery in the ear.
  • Paired magnets in both nostrils can cause septal necrosis.

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Swallowed Foreign Bodies and Food Bolus

• Fish or chicken bones:
  • Often stuck in the tonsil or base of tongue — look carefully with a good light and remove.
  • Lower down (pharynx, oesophagus) — lateral soft tissue neck X-ray (many bones are not visible), nasendoscopy, CT neck if persistent symptoms; rigid or flexible endoscopy.
  • Persistent pain, fever, neck swelling or surgical emphysema — perforation (deep neck infection, mediastinitis).
• Food bolus obstruction (oesophagus):
  • Sudden inability to swallow after eating (often meat); drooling; chest discomfort.
  • Can't swallow saliva = complete obstruction — urgent endoscopy (within 6 hours, per BSG/ESGE); otherwise within 24 hours.
  • Smooth muscle relaxants (e.g. hyoscine butylbromide, glucagon) are sometimes tried; evidence is weak and they shouldn't delay endoscopy.
  • After clearance — investigate the cause: eosinophilic oesophagitis (young men), stricture, cancer (older people).
• Swallowed button battery in a child — emergency X-ray; a battery in the oesophagus needs removal within 2 hours (can burn through in hours, causing fistula to the trachea or aorta). Some guidance advises giving honey (children over 1 year) on the way to hospital to reduce injury — follow local or national advice, and don't let it delay removal.
• Magnets (more than one) — risk of bowel perforation; urgent surgical review.
• Inhaled foreign body (children) — sudden cough, choking, wheeze, one-sided reduced breath sounds; rigid bronchoscopy.
• See the Gastroenterology Emergencies chapter.

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Drug Reference Table

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Spot the Emergency

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Exam-style Scenarios

1. A 45-year-old has 1 day of severe sore throat and can't swallow his saliva. His voice is muffled; the oropharynx looks almost normal. Temperature 38.6 °C.
Answer: Acute supraglottitis.

• Keep sitting up; no tongue depressor; senior anaesthetic and ENT help now.
• Oxygen, nebulised adrenaline, IV dexamethasone, IV ceftriaxone.
• Nasendoscopy in a safe setting; HDU/ICU; plan for awake intubation or tracheostomy if worsening.

2. A 78-year-old on apixaban has had a nosebleed for 90 minutes despite pressure. Blood is running down the back of his throat. Pulse 110.
Answer: Probable posterior epistaxis with anticoagulation.

• ABC; IV access, FBC, clotting, group and save; fluids.
• Topical vasoconstrictor; anterior pack; posterior or balloon pack if still bleeding.
• Tranexamic acid; discuss stopping or reversing apixaban with haematology.
• Admit under ENT; sphenopalatine artery ligation or embolisation if packing fails.

3. A 52-year-old woman woke with muffled hearing in her left ear and tinnitus. The ear drum is normal. Weber lateralises to the right.
Answer: Left sudden sensorineural hearing loss.

• Same-day ENT referral (NICE: within 24 hours).
• Audiogram; oral prednisolone (e.g. 1 mg/kg, max 60 mg) if no contraindication.
• MRI internal auditory meatus to exclude vestibular schwannoma.

4. A 74-year-old with type 2 diabetes has had 6 weeks of left ear pain and discharge not helped by drops. There is granulation tissue in the ear canal and a left facial palsy.
Answer: Necrotising otitis externa.

• Admit; swab; CRP and ESR; CT and MRI of skull base.
• IV antipseudomonal antibiotics, then prolonged oral ciprofloxacin.
• Tight glucose control; microsuction; biopsy to exclude cancer.

5. A ward patient with a 4-day-old surgical tracheostomy becomes distressed and hypoxic. There is no air movement through the tube.
Answer: Blocked or displaced tracheostomy.

• Call for help; high-flow oxygen to face and tracheostomy.
• Remove inner tube; pass suction catheter; deflate cuff.
• If no improvement — remove the tube; oxygenate via mouth or stoma; airway expert to re-intubate.

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Key Points

• Drooling, muffled voice and stridor mean airway danger — sit up, no tongue depressor, call senior anaesthetic and ENT help.
• Nebulised adrenaline and IV dexamethasone buy time; the definitive airway is in theatre.
• Bradykinin angioedema (ACE inhibitors, hereditary) has no urticaria and responds poorly to adrenaline.
• Tracheostomy: upper airway still connected. Laryngectomy: no connection — oxygen and ventilation via the stoma only.
• Epistaxis: lean forward and pinch the soft nose for 10–20 minutes; cautery, packing, tranexamic acid; check anticoagulants.
• Any bleeding after tonsillectomy needs hospital assessment.
• Quinsy: trismus, hot potato voice, deviated uvula — drain and give IV antibiotics.
• Ludwig's angina and deep neck abscesses threaten the airway; Lemierre syndrome follows a sore throat in young adults.
• Sudden sensorineural hearing loss is an emergency: refer within 24 hours; steroids; MRI to exclude schwannoma.
• Look in the ear in every facial palsy (Ramsay Hunt, cholesteatoma, otitis) and feel the parotid.
• Necrotising otitis externa: older diabetic, severe pain, granulation tissue — long antipseudomonal treatment.
• Drain auricular and septal haematomas promptly to prevent cauliflower ear and saddle nose.
• Button batteries in the nose, ear or oesophagus need immediate removal.