Musculoskeletal, Skin & HEENT · Topic 13 of 14

ENT Emergencies: Epistaxis, Deep Neck Infection & Pharyngitis

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HEENT · ENT emergencies

ENT Emergencies: Epistaxis, Deep Neck Infection & Pharyngitis

Ludwig angina can close the airway within hours. Most nosebleeds yield to compression; posterior bleeds need packing and a monitored bed.

01 · Ludwig anginaCan obstruct within hours: airway first

02 · Peritonsillar abscessTrismus, hot potato voice, uvular deviation

03 · Active epistaxisCompress lower nose 5 minutes or longer

Why Ludwig angina is an airway emergency

Ludwig angina can obstruct the airway within hours

Ludwig angina: floor-of-mouth swelling, laryngeal edema can obstruct airway

Infection is usually odontogenic, especially the 2nd and 3rd mandibular molars, and spreads as a bilateral cellulitis without a true abscess. It obstructs the airway more often than other neck infections.

What causes it

Most epistaxis is anterior, from the Kiesselbach plexus on the septum

Anterior epistaxis

Local traumaDrying of the mucosa

Posterior epistaxis

AtherosclerosisBleeding disordersPrior nasal surgery

Ludwig angina

Usually odontogenic

Adult retropharyngeal abscess

Foreign body ingestionInstrumentation

Hypertension may prolong a nosebleed but is unlikely to be its sole cause.

What you'll see

Muffled voice, drooling or stridor suggests epiglottitis or pharyngeal abscess

Ludwig: rapidly spreading bilateral cellulitis, floor of mouth + submandibular secure airway

Peritonsillar abscess: severe unilateral sore throat, trismus

Peritonsillar abscess: hot potato voice, uvular deviation hallmark

Retropharyngeal abscess in adults: severe neck pain

Posterior epistaxis: persistent bleeding with no anterior source

Lemierre: septic internal jugular thrombophlebitis after oropharyngeal infection

Lemierre: classically Fusobacterium necrophorum, with septic emboli

Cavernous sinus thrombosis: severe headache and fever first

Then ophthalmoplegia (CN VI first), proptosis, lid edema, often bilateral

Diagnosis & labs

Centor in adults: ≥ 2 criteria warrants group A strep testing

Centor: tonsillar exudate, tender lymphadenopathy, fever, no cough

0–1 Centor criteria: presume viral illness

2 or more Centor criteria: test for group A strep, antibiotics individualized

Retropharyngeal abscess: CT or a lateral neck film

Cavernous sinus thrombosis: confirm with MRI or CT

Epistaxis with suspected coagulopathy: CBC and PT/PTT

Recurrent bilateral bleeds or family history: search for HHT telangiectasias

Recurrent epistaxis: nasal endoscopy locates the source

Red flags

Sore throat with stridor or respiratory distress airway first

Sore throat with drooling or a muffled hot potato voice airway first

Visible pharyngeal bulge think abscess

Retropharyngeal abscess: airway obstruction, septic shock, rupture with aspiration secure airway

Retropharyngeal abscess: mediastinitis, carotid rupture, IJ thrombophlebitis drain

Sinusitis with periorbital swelling, proptosis or ophthalmoplegia order CT

Sinusitis with confusion or severe headache order CT

Epistaxis not controlled by packing or cautery ligation or embolization

Bleed not life-threatening: no reversal before first-line care first-line care first

Sore throat red flags suggest epiglottitis or pharyngeal abscess (see the upper airway sheet). Sinusitis can spread to orbital cellulitis, cavernous sinus thrombosis, epidural or brain abscess, meningitis or subdural empyema.

Treatment

First moves, by emergency

Ludwig angina: secure the airwayhighest priority

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Active epistaxis: firm compressionlower third of the nose, 5 min or longer, commonly 10

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Posterior bleed: balloon or posterior packoxygen, monitored unit

Ludwig anginaoral intubation is difficult

Clindamycin Ampicillin-sulbactam High-dose penicillin

Awake fiberoptic nasotracheal intubation in the OR or ICU, plus I&D

Tracheotomy if needed

Peritonsillar abscesscover aerobes and anaerobes

Penicillin 2 million units IV q4h Penicillin 1 g PO 4 times daily First-generation cephalosporin Clindamycin

Needle aspiration or I&D plus antibiotics, culture-directed for 10 days

Most patients go home

Retropharyngeal abscessstabilize the airway

Ceftriaxone IV Clindamycin IV

Stabilize the airway and give IV antibiotics

Drain for airway compromise, antibiotic failure, over 3 cm, immunocompromise or complications

Anterior bleedif pressure fails

Topical vasoconstrictor and anesthetic, then cautery limited to the site

Continues or no site visible: expandable foam or nasal balloon

Posterior bleedrhythm and airway monitoring

Amoxicillin-clavulanate 875 mg BID

Commercial balloon or posterior pack, oxygen, monitored unit

Remove balloons at 48–72 h, gauze packs at 4–5 days

On anticoagulantsunless life-threatening

First-line care before transfusion, reversal or stopping the drug

Use resorbable packing

Refractory bleedpacking or cautery failed

Sphenopalatine or internal maxillary ligation, or endovascular embolization

Lemierreantibiotics are the mainstay

Treat with antibiotics; no consensus on anticoagulation

Cavernous sinusthrombosis

Nafcillin or vancomycin Third-generation cephalosporin

Confirm with MRI or CT; give both antibiotics

Strep, aspiration, Lemierre drugs, fungal sinusitis

Group A strep causes perhaps 10–25% of adult sore throatsit matters for complications: abscess, rheumatic fever, glomerulonephritis

No pus on needle aspiration suggests peritonsillar cellulitisusually subsides within 48 hours on hydration and high-dose penicillin

I&D may recur less often than aspiration alone (low-quality evidence)

Lateral neck film may show widened prevertebral soft tissue

Retropharyngeal drainage is through the posterior pharyngeal wallintubate before surgery and maintain for 24–48 hours

Lemierre empiric options: piperacillin-tazobactam, a carbapenemor ceftriaxone plus metronidazole, covering beta-lactamase-producing anaerobes

Invasive fungal sinusitis, usually Aspergillus or Mucor, in immunocompromised patientsaggressive, sometimes fatal (see the invasive fungal infections sheet)

Posterior packing: watch for

Lower arterial PO₂

Airway compromise from pack migration

Pressure necrosis and sinusitis

Rarely toxic shock

Anterior or posterior epistaxis?

Persistent bleeding with no anterior source means think posterior

	Anterior	Posterior
Source	Kiesselbach plexus, anteroinferior septum	Posterior septum or turbinates
Frequency	Most nosebleeds	Less common, more serious
Usual setting	Local trauma, drying of the mucosa	Atherosclerosis, bleeding disorders, nasal surgery
Control	Compression, vasoconstrictor, cautery, foam or balloon	Balloon or posterior pack; admit to a monitored unit

Pearl

A hot potato voice, drooling or stridor means the airway comes first.