Acute throat / neck presentations

Throat / Neck Emergencies
Mr T Rockley (consultant ENT surgeon)

Haemorrhage after tonsil or adenoid surgery

Distinguish between reactionary (first 24 hours after surgery) or secondary (7-10 days postop) . In practice, reactionary haemorrhage virtually always starts within the first six hours after surgery.

Signs of reactionary haemorrhage in a child after adenoid or tonsil surgery are restlessness, pallor, rising pulse, excessive swallowing, or frank bleeding from mouth or nose. Confirm the diagnosis by looking at the child's throat using a torch and a tongue depressor. Once confirmed, it is important to tell the operating surgeon and anaesthetist that the child is bleeding. They will decide on whether the child needs to come back to theatre.

Secondary post-tonsillectomy haemorrhage, 7 - 10 days post-op, may often turn up to Emergency Department. Antibiotics and admission for overnight observation are required, even if they have apparently stopped bleeding.

Treatment of active bleeding:
Try gargles with 20% hydrogen peroxide 1 part in 3 parts water. If that doesn't work, spray the throat with lignocaine, remove any blood clot in the tonsil area using Luc's forceps, and try gargles again. If that doesn't work, inform the ENT consultant on call. As a last resort, after removing clot, apply adrenaline soaked swab to the bleeding site.

Epiglottitis

Acute epiglottitis is not common now that we have Haemophilus Influenzae immunisation in childhood. However, it still occurs in adults. It is best thought of as a local septic manifestation of a bacteraemia. Bacteriology is obtained from blood cultures, not from a throat swab. In adults, a variety of organisms may be responsible, not just H Influenzae.

Clinically, it is recognised by the combination of upper airway obstruction plus agonising dysphagia: it is so painful to swallow that the patient is even dribbling out their own saliva. The patient is ill, distressed and often toxic. The condition develops over several hours.

Differential diagnosis:
Other upper aero-digestive tract infections eg glandular fever, quinsy, parapharyngeal abscess. All of these conditions are obvious when you look in the patient's throat using a tongue depressor; in epiglottitis, the inflammation is much further down and so the back of the throat looks pretty much normal.

Management:
General management principles of patient with upper airway obstruction. Involve anaesthetists early.

Take blood cultures and put up a drip.
Give broad spectrum antibiotics Tazocin 4.5g tds. (cefuroxime if penicillin allergic)
Elective endotracheal intubation for 24 hours on ITU is usually required.

Acute tonsillitis

This is usually managed in general practice, but sometimes comes to hospital. Acute tonsillitis is often viral in origin. If the patient is toxic, or has a skin rash, or if there is obvious exudate on the tonsils, assume it is bacterial. Likely pathogens are streptococcus, haemophilus and staphylococcus.

Differential diagnosis:

Glandular fever
Quinsy

Management:

Take a throat swab for bacteriology. Make sure they have soluble analgesia available. Prescribe antibiotics if you think it is bacterial.
Only keep the patient in hospital if they cannot swallow any fluids, in which case they need IV rehydration for a day or so until they can swallow fluids.
If the swelling is enough to keep them in hospital then you may consider steroid treatment to help resolve any oedematous component. Dexamethasone 4mg BD for a day then a single dose is usually sufficient though may be doubled if you think necessary.

Quinsy (peritonsillar abscess)

This is a complication of acute tonsillitis It tends to occur in young people, ie teens and twenties, but can occur at any age. The abscess forms in the space between the tonsil and the pharyngeal wall. Microbiology of the abscess produces a mixed culture eg staph plus anaerobes.

Typically, the patient has had a generalised sore throat for a few days, and this then becomes lateralised to one side or the other. They cannot swallow without extreme pain, so they just spit out their saliva rather than swallow it.

On examination, the patient looks ill, possibly dehydrated as well. They cannot open their mouth more than a few centimetres (trismus) because the abscess causes spasm of the muscles which close the mouth. When you look at the throat, there is obviously much more swelling on one side than the other. The uvula is displaced to the opposite side.

Management: Drain the quinsy (see below) if it looks suitable and if the patient consents verbally. If they haven't had a quinsy previously, refer back to GP. If this is the patient's second or subsequent quinsy, they need interval tonsillectomy in about four to six weeks. Refer to ENT clinic.

Antibiotics
1st line benzylpenicillin with metronidazole.
2nd line clarithromycin with metronidazole id penicillin allergic

Draining a quinsy

Equipment needed :

Headlight or head mirror
Tongue depressor
Xylocaine spray
10 ml syringe with white needle
Cardboard bowl to spit into afterwards
Tissues to wipe the mouth afterwards

Procedure:

Position the patient sitting up on the examination couch in the treatment room.
Get the patient to open the mouth as much as possible; this is difficult and painful because the quinsy causes spasm of the muscles that close the mouth (trismus) so they can hardly open it much.
Spray the lignocaine sparingly at the area you are going to needle: this is the maximum bulge of the abscess if it is pointing. If it isn't obviously pointing, aim for a point on the soft palate halfway between the base of the uvula and the upper wisdom tooth on that side.
Explain that this is going to hurt, but it has to be done.
Push the tongue down with the tongue depressor, and stab the needle into the abscess (don't go more than 1 cm deep). Aspirate the abscess. Wait half an hour, then reassess the patient; if they can drink, they may go home with analgesics and antibiotics. If they can't drink, admit for analgesia, iv rehydration and antibiotics.

If you don't get any pus, you are either in the wrong place or it is cellulitis/oedema that hasn't quite got to the stage of abscess formation. Admit for analgesia, iv rehydration and

Antibiotics -
1st line benzylpenicillin with metronidazole.
2nd line clarithromycin with metronidazole if allergic to penicilin.

Review the next day

Glandular fever (infectious mononucleosis)

This viral infection is common in young people, teens and twenties, but can occur at any age. The infective agent is usually the Epstein Barr virus, but the clinical picture of GF can be produced by several different viruses. Typically, the disease lasts a week or so and then gets better. Although usually a benign disease, it is occasionally life-threatening if it is complicated by either spontaneous rupture of the spleen, or upper airway obstruction.

Clinically, there is painful enlargement of both tonsils, and large tender lymphnodes palpable in the neck. Always palpate the spleen for pain / enlargement.

Blood tests help in the diagnosis.

GF test: usually a red bottle - takes about a day.
FBC: In glandular fever, there is an increase in monocytes in the full blood count. This distinguishes it from bacterial tonsillitis, where there is a rise in the neutrophils.
Monospot test: diagnostic if positive, but unfortunately this test doesn't turn positive until about five days into the illness.

General management principles:

Once you have diagnosed GF, try to send the patient home if possible, to prevent hospital staff catching the illness. Advise them to take analgesia and plenty of fluids. Only keep the patient in hospital if they cannot swallow liquids, or if you think there is significant upper airway obstruction / risk of spenic rupture.

Don't prescribe amoxillin or ampicillin; this will cause a rash and is considered negligent.

Airway obstruction

General management principles:

Distinguish between upper airway obstruction (stridor) and lower airway obstruction (wheezing or asthma).

If upper airway obstruction is diagnosed:

Immediately inform the on-call ENT consultant and the on-call anaesthetist.
If the patient is a child, refer to paediatrics.
Have oxygen and suction available and keep the patient close to full resuscitation equipment.
Apply a pulse oximeter.
Ask someone to fetch the equipment for laryngoscopy: the flexible laryngoscope and its light source.

Assess the severity of stridor by noting the following: respiratory rate, presence of cyanosis, use of accessory muscles (chest, neck) for respiratory effort. Desturation on pulse oximetry or disturbed blood gases indicate poor compensation.

Assess the site of the stridor by noting whether it is inspiratory, expiratory or both.

Note the associated symptoms: If the patient has a hoarse voice, this suggests there is disease of the larynx itself. If the patient has dysphagia (difficulty swallowing) this suggests they might have epiglottitis.

Possible causes of upper airway obstruction:

Foreign body in larynx
Tumour of larynx
Retropharyngeal abscess
Acute epiglottitis
Psychogenic / hysterical
Glandular fever with tonsil enlargement

Upper Airway Foreign Bodies

They cause stridor and coughing and need urgent consultation with on-call anaesthetist . FBs in the bronchial tree may present with minimal symptoms: watch out for a history of choking, or recurrent chest infections and a monophonic wheeze. CXR may show segmental collapse.

As with oesophageal FBs, the patient must not be discharged until you are sure there is no foreign body present.

Foreign bodies in the throat / oesophagus

Usually fishbones, meatbones or impacted meat bolus in adults, coins in children.

Fishbones: 60% are in the tonsils, 15% in the base of the tongue, the rest elsewhere or further down. General points to remember are that fishbones are cartilage, hence do not usually show up on X-ray. Remember also that the patient must not be discharged from follow up unless you are sure there is no fishbone there. A "scratch" on the throat feels like a foreign body, but the sensation gets better over 24 - 48 hours, so bringing them back the next day sometimes resolves the dilemma if you are not sure.

Other oesophageal foreign bodies (food boluses, meatbones and coins) usually stick at the upper oesophageal sphincter, adjacent to C6 on a lateral soft tissue neck X-ray. This is the narrowest part of the GI tract, and if a coin has passed lower down, it. may be expected to go all the way through. Sharp foreign bodies obviously require endoscopy. Other "sticking points" in the oesophagus are the arch of the aorta, lower sphincter, and any underlying pathologies (e.g. peptic strictures). If the oesophagus is completely obstructed with a meat bolus, the patient will be unable to swallow their own saliva, and will be spitting it out.

Lateral soft tissue X-ray:
Signs of FB on a lateral soft tissue neck X-ray are loss of normal cervical lordosis, thickening of prevertebral soft tissue shadow, air in the prevertebral soft tissues, air bubble in the oesophagus, and of course the FB itself if opaque.

Management:

Fishbones in the tonsil are best removed with Luc's forceps. Spray the throat with lignocaine first.
Fishbones in the tongue base / vallecula need removal using a laryngeal mirror, local anaesthetic spray and Luc's forceps. Ask the patient to pull their tongue out and hold it with a gauze square, while taking slow deep breaths in and out of their mouth. You hold the mirror against the uvula using one hand, and try to grab the foreign body with the Luc's in the other. (This needs a bit of ENT experience!)
FBs in the oesphagus need admission, iv access, and prep for endoscopy on the next available ENT operating list.

Luc's Forceps

Trauma to the neck

Laryngeal trauma and penetrating laryngeal injuries are rare, but need urgent admission because of the risk to the airway. Often occur in the multiple injured RTA and hence may be missed.

Stab wounds in the neck similarly require admission. Please inform the ENT consultant on call.

Updated 02/07/09