Ear Trauma + Epistaxis

Question 1

What kind of injury causes a pinna haematoma?

Answer 1

Shearing force to auricle e.g. rugby, boxing

Question 2

What is the pathology of a pinna haematoma?

Answer 2

Blood between cartilage and overlying perichondrium 
--> blood supply to cartilage impaired
--> AVN of cartilage if untreated
Subsequent fibrocartilage overgrowth 
--> cauliflower ear

Question 3

How should a pinna haematoma be managed?

Answer 3

Haematoma drained within 24 hours

Then gauze padding + tight headband to prevent re-accumulation

Question 4

What are the main points for managing a pinna laceration?

Answer 4

Clean thoroughly under local anaesthetic
Consider tetanus boosters + antibiotic prophylaxis if required
All cartilage must be covered with skin (otherwise no blood supply for healing)

Question 5

How are temporal bone fractures classified?

Answer 5

Longitudinal (most common) or transverse –> depending on relation to ear canal axis

Question 6

Which type of injury causes a longitudinal temporal bone fracture, and which type of hearing loss may occur?

Answer 6

Lateral blow to the head

Conductive hearing loss

Question 7

Which type of injury causes a transverse temporal bone fracture, and which type of hearing loss may occur?

Answer 7

Fronto-occipital trauma

Sensorineural hearing loss

Question 8

Which clinical features may occur with a temporal bone fracture?

Answer 8

Facial nerve palsy
Post auricular ecchymosis –> battle sign
Haemotypanum, TM rupture
Irregular step in ear canal, canal laceration
Hearing loss
CSF otorrhoea or rhinorrhoea

Question 9

What causes the battle sign?

Answer 9

Rupture of posterior auricular artery due to basilar skull fracture

Question 10

How should a temporal bone fracture be managed?

Answer 10

Prompt CT
Admit for neuro-observation
Discuss at MDT re. surgery
Most cases managed conservatively

Question 11

How is a traumatic TM perforation managed?

Answer 11

Majority heal within 2-3 months
Advice on strict water precautions to avoid secondary infection
Myringoplasty if non-healing

Question 12

Describe the blood supply to the nose

Answer 12

Internal carotid –> ophthalmic –> anterior and posterior ethmoidal
External carotid:
- facial –> lateral nasal + septal branch of superior labial
- maxillary –> greater palatine + sphenopalatine

Question 13

What is the most common site of bleeding in epistaxis?

Answer 13

Little’s area (Keisselbach’s plexus)

–> anastomosis on anterior septum

Question 14

Which features are important to ask about in an epistaxis history?

Answer 14

Bleeding from one or both nostrils initially? Blood down back of throat?
Trauma, co-morbidites, family history, drug history, previous episodes
Facial pain, otalgia, systemic symptoms, features of clotting disorders

Question 15

How can you tell the difference between an anterior and posterior nose bleed?

Answer 15

Anterior (Little’s area):
- usually starts from one nostril, then blood swallowed after first aid applied

Posterior:

• usually heavy bleeding from both nostrils from the start with blood being swallowed from the onset
• majority of blood may be swallowed giving false appearance of severity

Question 16

What is the initial management of epistaxis?

Answer 16

ABCDE (may have lost a lot of blood)
All patients sat up + lean forward to encourage blood out of nose and not into pharynx
Encourage to spit blood out
1. Compression
2. Cautery with silver nitrate

Question 17

How is compression carried out in management of epistaxis?

Answer 17

Pinch soft part of nose for 20 minutes without releasing pressure
Can apply ice to bridge of nose or ice in mouth to stimulate vasoconstriction

Question 18

How is nasal cautery carried out in management of epistaxis?

Answer 18

Anterior rhinoscopy to visualise bleeding vessel

Apply end of cautery stick –> chemical burn

Question 19

What is the next step in management of epistaxis is no bleeding point can be seen or cautery fails?

Answer 19

Anterior packing with rapid rhino, merocel, nasal tampon
–> ensure analgesia (painful for patient)
Send FBC, clotting + G&S if not done already
Reverse any causes e.g. INR
If lots of blood entering oropharynx –> posterior packing with Foley catheter

Question 20

What are the surgical management options for epistaxis?

Answer 20

Endoscopic sphenopalatine artery ligation under GA
- other arteries may be ligated e.g. maxillary, ethmoidal (anterior), external carotid
Embolisation with interventional radiology is also an option

Question 21

What is the step wise approach to managing epistaxis?

Answer 21

1. Compression
2. Cautery with silver nitrate
3. Anterior (or posterior) packing
4. Endoscopic sphenopalatine artery ligation
5. Other artery ligation
6. Embolisation