True ear, nose, and throat emergencies—airway obstruction, posterior nose bleeds, or severe head and neck infections— while definitely requiring emergent ENT referral, are rarely a diagnostic dilemma. Much more difficult are the ENT “urgencies,” situations and diseases that may seem rather benign but where delay in definitive treatment could cause significant problems.
Being aware of a few of these situations may result in initiating rapid treatment and appropriate referral.
Sudden Hearing Loss
Rapid hearing loss in adults can be one of the most difficult situations to correctly diagnose and treat. The majority of the time, especially in the setting of an upper respiratory illness or airplane flight, sudden hearing loss is related to serous otitis media (SOM). SOM is a non-urgent problem, best treated with decongestants, steroid nasal sprays, and time. Up to 80% will resolve in 6-8 weeks. However, sudden sensorineural hearing loss is due to inner ear injury, may also be associated with viral symptoms, and can present similarly. The key to treatment is the early institution of high dose prednisone, usually 60 mg a day for 10 days, as this has been the only clinically proven regimen to improve hearing. Recent reports of intratympanic steroid injection, either as primary treatment or as salvage treatment, have also been promising and can be used where systemic steroids may be contraindicated. Ideally, treatment should be started in days after onset; waiting weeks likely diminishes the chance of improvement. The key to diagnosis of sudden sensorineural hearing loss is documenting the rapid onset of hearing loss in the absence of middle ear effusion. Physical exam usually is sufficient, but errors are not uncommon, especially if the eardrum is dull, thick, or difficult to visualize. A tympanogram can be extremely helpful. The gold standard in diagnosis is a complete audiogram, which can differentiate between sensorineural loss and conductive loss. These tests can be ordered through the Ear, Nose and Throat Center, either with or without a formal consultation.
The diagnosis of Bell’s Palsy is usually not difficult, as rapid onset of facial weakness is quite evident to both patient and physician. Starting oral prednisone as well as antivirals (acyclovir or Famvir) have been shown to improve outcome, and should be begun as soon as possible. The difficulty in treatment, however, revolves around predicting which patients have an excellent chance of spontaneous improvement and which have a higher chance for permanent synkinesis or weakness. Any patient who has some perceptible motion has a very good chance at recovery and no further testing or evaluation is required. Total weakness— no motion at any branch, incomplete eye closure—must be further evaluated. Electroneuronography (EnOG) is a neurodiagnostic test comparing the facial nerve action potential of the affected side to the normal side. Beginning around day 3 after onset, EnOG testing showing 90% or higher degeneration is a strong indicator for poor prognosis, and often serial testing every 2 days or so is helpful to follow trends. If degeneration reaches 90%, surgical facial nerve decompression has been shown to significantly improve functional outcome, as long as it is done within the first 14 days after onset. The upshot: Early steroids and antivirals, and quick referral for any complete facial weakness.
Nasal fractures are common and not particularly difficult to diagnose. In fact, this is almost purely a clinical diagnosis, and x-rays are rarely necessary or helpful. There are two reasons to fix a nasal fracture: nasal airway obstruction or external nasal deformity. The key to treatment is timely, appropriate referral. Seeing a patient before 3-4 days after the injury is rarely helpful, as swelling masks the external contours. However, by 14 days after injury, fibrous tissue has begun to develop and resetting the bones becomes unproductive. Any patient with continued difficulty breathing through their nose or concerns about their nasal appearance at 4 days after injury should be seen quickly. The physicians at the Ear, Nose, and Throat Center are more than willing to help you in the management of these and other “urgencies” you may encounter, and will work with your staff to rapidly evaluate and treat your patients.