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1. ENT emergencies Ayan Abdurrahman Egeh MBBS, FMmed

2. Epistaxis

3. Introduction Epistaxis is one of the most common otolaryngologic emergencies, occurring in up to 60% of the general population, with one in 10 of those affected seeking medical attention. It accounts for one in 200 emergency department visits.  Epistaxis has a bimodal age distribution, peaking in children younger than 10 years and in adults between 70 and 79 years of age . Males are slightly more likely to experience epistaxis than females

4. Anatomy Approximately 90% of epistaxis cases arise from the anterior part of the nasal septum; this is known as anterior epistaxis. Anterior bleeding most commonly occurs from the rich vascular supply at the Kiesselbach plexus  This plexus is formed by terminal branches of the internal carotid artery (anterior and posterior ethmoidal arteries) and external carotid artery (sphenopalatine, superior labial, and greater palatine arteries)

5. Anatomy Posterior epistaxis typically occurs along the nasal septum or lateral nasal wall, and originates from branches of the internal maxillary, sphenopalatine, and descending palatine arteries. The posterior ethmoid artery provides a small contribution. Because hemostasis is more difficult to achieve with posterior bleeding, the distinction between anterior and posterior epistaxis guides management

6. Etiology A focused history and physical examination identify most causes of epistaxis

7. Physical Examination The physical examination should begin with assessment of vital signs mental status airway patency.

8. Nasal examination When examining the nose, a nasal speculum and good light source, such as a head-lamp, are useful. Look for bleeding The Kiesselbach plexus Vestibule Septum turbinates . posterior bleeding?

9. Management ANTERIOR EPISTAXIS conservative - invasive means to achieve hemostasis . An initial assessment of airway patency is necessary. compressive therapy application of cotton soaked in epinephrine 1:1,000 may be useful to abate or slow the bleeding. Directive therapy. topical therapy and nasal packing are the next options. abx

10. Management Posterior epistaxis More likely to require hospitalization and are twice as likely to require nasal packing. A B C   Require referral to an otolaryngologist after stabilization. Posterior nasal packing  endoscopic or surgical management

11. Posterior nasal packing

12. Ludwig’s angina

13. INTRODUCTION Ludwig's angina is a serious, potentially life-threatening cellulitis, or connective tissue infection, of the floor of the mouth, usually occurring in adults with concomitant dental infections. If left untreated, may obstruct the airways, necessitating tracheotomy. It is named after the German physician, Wilhelm Friedrich von Ludwig who first described this condition in 1836 . The microbiology of Ludwig’s angina is polymicrobial and includes many gram positive eand negative aerobic/anaerobic organisms.

14. Anatomy The submandibular space is divided into the sublingual, supramylohyoid and inframylohyoid portions by the mylohyoid muscles 

15. Anatomy The submandibular space is in direct communication with the sublingual space in the posterior aspect, which leads to easy spread of the infection The end result is edema and posterior displacement of the tongue and possibly epiglottis, leading to potential airway compromise

16. Etiology Odontogenic infections account for over 90% of cases .  Additional etiologies include mandible fracture neck trauma tongue piercing Sialdenitis neoplasm other parapharyngeal infections Polymicrobial infection occurs in over 50% of cases.

17. Risk factors The majority of cases of Ludwig's angina occur in healthy patients with no comorbid diseases .   possible predisposing factors diabetes mellitus Alcoholism acute glomerulonephritis systemic lupus erythematosus aplastic anemia Neutropenia dermatomyositis .

18. Clinical presentation The majority of patients report dental pain history of recent dental procedures neck swelling . Less common complaints include neck pain Dysphonia Dysphagia dysarthria . Less than one third of adults will present in respiratory distress with dyspnea , tachypnea , or stridor.

19. physical examination over 95% of patients have bilateral submandibular swelling and an elevated or protruding tongue The submandibular swelling is often characterized as brawny and tense, with overlying erythema . Surprisingly, generally there is no cervical lymphadenopathy.

20. management Airway management Antibiotics should be initiated as soon as possible. Antibiotics should initially be broad-spectrum and cover gram-positive, gram-negative, and anaerobic organisms. Combinations of penicillin, clindamycin, and metronidazole are typically used. The value of corticosteroids in the setting of Ludwig's angina is unclear . Surgical incision plus drainage was the therapy of choice in the preantibiotic era. With the exception of dental extractions, surgery is reserved for patients who do not respond to medical therapy and those with crepitus and purulent collections,