AAO-HNSF Primary Care Otolaryngology Handbook

ENT EMERGENCIES

Choanal atresia is a congenital disorder in which the nasal choana is occluded by soft tissue, bone, or a combination of both. When unilateral, it presents with unilateral mucopurulent discharge. When bilateral, the neonate is unable to breathe. Since newborns are obligate nasal breathers, establishing an airway is an acute otolaryngologic emergency. While this should be done in the operating room, a Montgomery nipple can be used as an interim measure prior to surgery. Difficult Intubations Anatomic characteristics of the upper airway, such as macroglossia or congenital micrognathia (e.g., Pierre Robin syndrome), can result in difficult laryngeal exposure. This syndrome is more commonly encountered in young, muscular, overweight men with short necks. Anesthesiologists are trained to recognize and manage the airway in these patients, but everyone caring for them must be aware of the potential difficulty. The need for a surgical airway in these patients often represents a failure of recognition and planning. Ludwig’s Angina and Deep Neck Infections Ludwig’s angina is an infection in the floor of the mouth that causes the tongue to be pushed up and back, eventually obstructing the patient’s airway (Figure 3.1). Treatment requires incision and drainage of the

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abscess . The most common cause of this abscess is infection in the teeth. The mylohyoid line on the inner aspect of the body of the mandible descends on a slant , so that the tips of the roots of the second and third molars are behind and below this

line. Therefore, if these teeth are abscessed, the pus will go into the submandibular space and may spread to the parapharyngeal space . Patients with these infections present with unilateral neck swelling, redness, pain, and fever. Usually, the infected tooth is not painful. Treatment is inci- sion and drainage over the submandibular swelling. Antibiotic coverage should include oral cavity anaerobes . If, however, the tooth roots are above the mylohyoid line, as they are from the first molar forward, the infection will enter the sublingual space , Figure 3.1. This photograph depicts a gentleman with severe Ludwig’s angina. Notice the swollen floor of the mouth and the arched, protruding tongue obstructing the airway.

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