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FACEM Written > ENT > Flashcards

ENT Flashcards

1
Q

Zones - Neck

A
  • Zone 1 - clavicle to cricoid cartilage
  • Zone 2 - cricoid cartilage to angle of mandible
  • Zone 3 - angle of the mandible to base of skull.
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2
Q

Neck Trauma Signs

A

Hard signs assoc 90% major injury
Hard signs straight to OT - only delay to secure airway
Soft signs CT angiogram neck
No significant signs observation

Vascular hard signs
Active bleeding, Large expanding haematoma, , bruit/thrill, reduced GCS, shock, focal neuro deficit
Vascular soft signs - Minor bleeding, small haematoma

Aerodigestive hard signs
Aphonia (severe), Respiratory distress, Stridor, Haemoptysis, Haematemesis, Air/bubbles in wound
Aerodigestive soft signs - dysphagia, dysphonia, SC air

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3
Q

Epiglottitis

A

Orgs

Hib > Strep, Staph

PSeudomonas/Candida - immunocomp

OA

Toxic / Stridor / Resp distress / Posturing

DDx

Croup

Bacterial tracheitis

Diphtheria

Per-tonsillar abscess / Retropharygeal abscess

CXR

Thumbprint sign

Mx

Calm

O2

Nebulised adrenaline

IV ABx - ceftriaxone

IV dexamethasone

ETT

ICU/Anaesthetics/ENT

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4
Q

Epistaxis - blood supply

A

ANTERIOR

Anterior + Posterior ethmoid artery

Superior labial artery

Greater Palatine Artery

Sphenopalatine artery

POSTERIOR

Sphenopalatine Artery

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5
Q

Malignant Otitis Externa

A

Necrotising otitis externa

HIGH MORTALITY

Continguous spread to cartilage, periosteum, soft tissues, bone

Orgs

Pseudomonas

MRSA

Fungal - immunocomp

Consider in those Rx for Otitis Externa for 2-3 weeks + otaligia + ottorhoea

OA

Toxic

Cranial nerve

Intracranial extension

Ix

CT/MRI

Mx

IV cipro 400mg TDS

ENT admit

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6
Q

Tinnitus

A
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7
Q

Sudden Hearing Loss

A

< 3 days, > 30dB

Poor prognosis = Severe Hearing loss + vertigo

70% Idiopathic

13% Infectious

Others - otologic Dx, trauma, vascular, haem, neoplastic

OA

Ear exam

Weber + Rinne test

Mx

ENT referral

Poor evidence for other modalities

  • Steroids PO
  • Steroids Intratympanic
  • Hyperbaric oxygen
  • Antiviral therapy
  • Vasoactive / Hemodilution therapies/dextran/Mg
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8
Q

Conductive Hearing Loss

A

Cerumen

FB

Serous OM

Otitis Externa

Neoplastic

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9
Q

Acute Suppurative Otitis Media

A

Mixed bacterial / viral infection of middle ear
Orgs: Strep penumoniae > Hib > Moraxella catarrhalis

Presentation
Signs/Sx of middle ear inflammation +
Bulging TM, Erythema, otalgia, fever
Middle ear effusion
TM opacity, dec TM mobility, Air-fluid level, ottorhoea

Immediate Abx for:
Systemic features
TM rupture
Indiginous
Difficult follow up
Age
- < 6mo
- 6-24 mo if no improvement in 24 hrs
Only hearing ear or cochlear implant

Mx
* Kids < 2yrs = Treat 10d
* Kids > 2yrs = treat if unwell or in 48hrs x5d
* Adults = treat x10d
Kids with tubes = ciproHC BD x7d
ABx choice
* Amoxycillin 30mg/kg BD
* Aug if Rx failure 22.5mg/kg BD

Complications:
Meningitis
Mastoiditis
Intracranial abscess
Lateral sinus thrombosis
Facial nerve paralysis
Middle ear effusion
Chronic OM - glue ear

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10
Q

Bullous Myringitis

A

Infection => blistering of TM

Orgs Associated

S. pneumoniae

M. attarhalis

H. influenzae

M. pmeumonia

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11
Q

Complications AOM

A

Intra-temporal

  • Failure of Rx = > ENT referral
  • TM retraction w/ hearing loss
  • TM rupture
  • Ossicular erosions
  • Retraction poscke formation
  • Chronic supporative otitis media
  • Cholesteatoma
  • Mastoiditis

Extra-temporal

  • Meningitis
  • Epidural abscess
  • Brain abscess
  • CSVT
  • SD empyema
  • Carotid artery thrombosis
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12
Q

Post-tonsillectomy bleeding

A

Primary w/in 24 hrs post-op

Secondary > 24hrs

  • MOVIE
  • Immediate large bore IVC x2
  • Hb, X match, G+S
  • IVF 10mls/kg if shocked
  • TXA bolus
  • Transfusions reqiured in 10-12% of secondary bleeds.
  • Early Referral to ENT help early
  • Topical adrenaline on gauze pressure on bleeding point, if tolerated by the patient
  • Silver nitrate cautery may be attempted.
  • Antibiotics if infection suspected (ENT use it regardless).
  • Steroids
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13
Q

Salivary Gland Swelling

A
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14
Q

Sialolithiasis

A

Stone in salivary gland, > 80%submandibular gland

See DDx Salivary gland swelling

Viral: Mumps

Bacterial : Staphylococcus, Streptococcus viridans, S. pneumoniae, and H. influenzae

OA

Clinical exam with palpation

Ix

CT / USS - size and location of stone

Mx

  • MMassage/heat
  • Sialagogues (ex lemon candies to promote salivation)
  • Antibiotics if infection suspected (fever, increasing pain, purulent d/c)
  • Lithotripsy as per ENT
  • Treatment failure may end with surgical removal of entire gland
  • ENT F/U important immediately if stone cannot be removed in ED, or within 4-5 days if it can be.
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15
Q

DDx neck Masses

A
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16
Q

Cholesteatoma

A

Keratinised desquamated epithelial collection in middle ear or mastoid process (AbN collection of skin within middle ear cleft)

Painless hearing loss

Foul smelling D/C - scant

OA

Pearly mass evident behind TM

Mx

Refer to ENT OPD unless acute complication

Complications:

Intra-temporal

  • Loss of hearing
  • Infection

Extra=temporal

  • CN VII palsy
  • Meningitis
  • Temporal lobe abscess
  • CVST
  • Vertigo/Nystagmus
17
Q

Ramsay Hunt Syndrome

A

Herpes Zoster Oticus

Ipsilateral CN VII palsy + otalgia + vesicles auditory canal

CN VIII - hearing and balance impairment

Rx

Analgesia

Antivirals : valaciclovir 1g TDS / acyclovir 800mg 5x daily

18
Q

Mastoiditis

A
19
Q

Epistaxis Mx

A

ANTERIOR

  • Direct pressure
  • Silver nitrate (bad with active bleeders)
  • Cautery (don’t use longer than 10-15 seconds can perforate) start peripheral to central
  • Bilateral septal cautery not advised
  • Can use gelfoam or surgical
  • Rapid Rhino or epistats (leave in for 48-72hrs)
  • ? ABx reduce risk of TSS

POSTERIOR

  • Large bleed despite adequate anterior packing
  • Rapid Rhino or Foley
  • REMEBER NEED TO APPLY TRACTION
  • Pack both nares with foley, inflate balloon w/ sterile water, tug until well seated, apply traction (use green umbilical clamps)
  • Leave packs in for 2-5days as per ENT
  • ABx important (Keflex or Amox-Clav)
  • Refractory cases may need CT and IR
20
Q

Epistaxis Causes

A

IDIOPATHIC

LOCAL

  • Trauma - injury or FB or Picking
  • Traumatic internal carotid artery aneurysm
  • Infection - URTI, nasal mucormycosis, neonatal
  • Environment - Low humidity, irritants
  • Allergies
  • Drugs - cocaine
  • Lesions - polyps

SYSTEMIC

  • Coagulopathy - DOACs, blood dyscrasias, DIC
  • Hepatic Disease
  • DM
  • EtOH abuse
  • Renal diseas - chronic nephritis
  • Drugs - chemo, drug induced thrombocytopaenia
  • Metabolic - vit K / folic acid deficiency
21
Q

Drug Induced Tinnitus

A
22
Q

Deep Neck Spaces

A
23
Q

Deep Neck Space infections

A

PERI-TONSILLAR

RETROPHARYNGEAL - ENT Emergency

  • space extends from base of skull to superior mediastinum
  • usually < 6years old

PARAPHARYNGEAL

  • odontogenic or pharyngotonsillar infection or contiguous spread from other deep space neck infections
  • Polymicrobial

MASTICATOR

  • submandiubular / sublingual

OTHER FEATURES:

  • Polymicrobial - Rx TAZ / cex + met / clindamycin
  • Comp:

> Airway obstruction

> Continguous spread → Mediastinitis, mediastinal or myocardial abscess

> Abscess rupture, aspiration pneumonia + empyema

> Lemierre’s syndrome - septic thrombosis if IJV

  • pharyngitis followed by severe sepsis
  • Dispo: ICU +/- OT for I+D
24
Q

Lemierre’s Syndrome

A

Septic thrombophlebitis of IJV + bacteraemia

Pharyngitis followed by severe sepsis

EPI

  • mostly affects children, adolescents and young adults
  • delayed diagnosis is common

MICRO

  • fusobacterium species, especially fusobacterium necrophorum most commonly (an anaerobic GNB, a part of normal oral flora)
  • ⅓ polymicrobial bacteraemia (anaerobic strep + gm -ve anaerobes)
  • other gram positive causes have been reported (e.g. S.aureus)

PATHOPHYSIOLOGY

Primary infection is followed by local invasion of the lateral pharyngeal space then septic thrombophlebitis of the IJ vein

  • primary source of infection is commonly the palatine tonsils and peritonsillar tissue
  • Metastatic infections following the IJ thrombophlebitis occur in >2/3 of cases
  • lungs, joints, liver, muscle, pericardium, brain and skin

COMPLICATIONS

  • Thrombosis may propagate from the IJ vein inferiorly into the subclavian vein or superiorly into the cavernous, sigmoid or transverse sinuses
  • metastatic infection
  • DIC (~5%)
  • meningitis (3%)
  • septic shock
  • death (near 100% mortality in the pre-antibiotic era)

CLINICAL FEATURES

Clinical manifestations vary according to the presence of metastatic complications

  • Fever (but may appear otherwise well)
  • Pharyngitis/peritonsillar abscess
  • Anterior cervical lymphadenopathy
  • Neck mass/tenderness (~50%)
  • Trismus
  • Cranial nerve 10, 11, 12 palsies
  • Septic arthritis (most commonly hip or knee)
  • Jaundice/hepatomegaly
  • Shock

INVESTIGATIONS

  • Septic screen
  • Joint fluid aspirates if appropriate

Imaging

  • CXR — metastatic infection of the lungs is common: nodules, cavities, effusions
  • CT Neck with contrast — IJV thrombophlebitis and/or neck mass/ collections

MANAGEMENT

Resuscitation

  • address life threats such as airway compromise, respiratory failure and septic shock

Specific therapy

  • Supportive care and monitoring
  • antibiotics
    • if severely unwell: piperacillin+tazobactam 4/0.5 g (child: 100+12.5 mg/kg up to 4/0.5 g) IV q8h
    • if systemically unwell: benzylpenicillin 1.2 g (child: 50 mg/kg up to 1.2 g) IV q6h AND metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV q12h
    • if systemically well: amoxicillin/ clavulanate or clindamycin
    • typically 2-6 weeks duration
  • anticoagulation
    • controversial (administered in about 1/4 to 1/3 of case reports)
    • some recommend if IJ thrombophlebitis leads to venous sinus thrombosis or failure to improve with antibiotics
25
Q

Penetrating Neck Trauma - Nerve Injuries

A
  1. Subclavian vein/artery injury → Phrenic n → hemidiaphragm paralysis
  2. Common Carotid or IJV → Vagal n → tachycardia
  3. Thyroid+/- tracheo-oesophageal injury → Recurrent laryngeal n.
  4. Sympathetic chain → Horner’s syndrome
26
Q

Perichondral Haematoma

A

Need to drain to prevent permanent cartilage destruction leading tocauliflower ear deformity

CI
Haematomas > 7 days
Recurrent haematoma

Referral to ENT
1. Large overlying skin avulsion
2. Severe crush injury
3. Devitalised tissue
4. Complete or near complete avulsions / amputations
5. Large cartilage defects > 5mm
6. Involvement of auditory canal

FACEM Written (34 decks)

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