ENT Flashcards
What is an auricular hematoma and their management
Blood beneath the perichondrium typically from blunt trauma and if left untreated can cause deformity and destruction of the cartilage (cauliflower ear). Either procedure should be followed by compression bandage and Hematomas that are both anterior and posterior require the bolsters to be sutured together with monofilament suture; dental rolls are particularly suited for this maneuver. Can also use plaster and mold to ear. ENT follow up needed and oral abx (cipro)
Needle aspiration
- small hematomas <2cm
- present less than 48hrs
18G to most fluctuant part of hematoma while milking ear followed by manual pressure for 3-5 minutes
I&D
- Hematomas >2cm, present between 2 and 7 days and hematomas that reaccumulate after needle aspiration
Incision along most superior aspect of helix no longer then 1cm.
Curved hemostat to break and milk hematoma
Irrigate with saline
Manual pressure for 3-5minutes
What are some contraindications for ED evacuation of auricular haematomas and what are some complications
Contraindications
- Cellulitis
- unreparied laceration with exposed cartilage
- Chronic or recurrent haematomas (>7 days old)
Complications
- infection
- chondritis
- deaccumulation of the haematoma
When should ear injuries be referred to surgery
Large overlying skin avulsion >5mm
Severe crush injuries
Complete or near complete avulsions/amputations
Obvious devitalisation
Large haematomas
Significant auditory cannal involvement
How do you perform an ear block
Enter the skin at a point below the ear and advance the needle posteriorly over the mastoid behind the ear.
Inject 2ml lignocaine as needle is withdrawn
Without leaving the skin redirect the needle and inject 2ml while advancing anteriorly making a V shaped track
Repeat above the ear to make an inverted V
Wait 10-15 minutes
What is the pathophysiology of retropharyngeal abscess?
Most commonly in children 2-4yrs old but can occur at any age.
Secondary to suppurative lymphadenitis or direct trauma
Children have 2 chains of lymph nodes in the retropharyngeal space that atrophy before puberty
They drain from drain from the nasopharynx, adenoids, posterior paranasal sinuses, middle ear and eustachain tube so infections in these spaces can cause supporative adenitis
Recent URTI associate with 50% of retropharyngeal abscesses
1/4 of cases occur from pharyngeal trauma (dental procedure, endoscopy, penetrating trauma, intubation attempt)
Progresses from cellulitis to organized phlegmon to mature abscess and management depends on stage
How do retropharyngeal abscess present
Sore throat (76%)
Fever (65%)
Torticollis (37%)
Dysphagia (35%)
Dysphonia
Dyspnoea
Neck swelling
Cervical lymphadenopathy
Hoarse voice
Drooling
Inability to protrude tongue -> imminent airway obstruction
What are the microorganisms of retropharyngeal abscess?
Polymicrobial with predominantly
- Streptococcus (Group A)
- Staph aureus (including MRSA)
- Respiratory anaerobes (Fusobacteria, prevotella, veillonella)
- Haemophilus species found less commonly due to vaccinations
What are the complications of retropharyngeal abscess?
Airway obstructions
Septiciema
Aspiration pneumonia if abscess ruptures into airway
Internal jugular vein thrombosis
Jugular vein suppurative thrombophlebitis (Lemierre syndrome)
Carotid artery aneurysm, compression or rupture
Mediastinitis
Osteomyelitis of cervical spine or antlantoaxial dislocation
Spinal cord abscess
What is the imaging and management of retropharyngeal abscess and when would surgery be considered?
CT is gold standard
Lateral neck xray may
- thickening of the paravertebral space (>full vertebral body at C2/3 when pt<5 , >7mm at C2 at >5yrs. Also >14 at C6 for children and >22 at C6 for adults)
- loss or reversal of the normal cervical lordosis
- Air fluid level or prevertebral gas mass be seen
Manage with IV augmentin (25mg/kg) +/- Vancomycin 25mg/kg
Surgery indicted for airway compromise or life threatening complication
Large mature abscess with complete rim enhancement on CT ≥2.5 cm2
Failure to respond to IV abx for 24-48hrs and development of large abscess
What are the 2 forms of post tonsillectomy bleed
Primary - <24 post from failure of primary haemostasis or slipped ligature (more severe)
Secondary - 1 to 14 days post (5-7 most common) from breakdown of fibrin clot
What are some management steps for management of ongoing post tonsillectomy bleed
- Sit up right
- Secure airway if needed
- Large bore IV access and resuscitation if needed
(FBC, Coags, Group and crossmatch) - NBM, ice to back of neck
- Headlamp, good visualisation, suction
- Hydrogen peroxide gargles if not severe with 3% diluted in 3 parts water
- Topical constrictors (cophenlocaine spray) / nebulised adrenaline
- Silver nitrate cautery if small bleeding point identified
- Tranexamic acid 15mg/kg (1g)
- IV benzylpenicillin and metronidazole
- Last resort after intubation direct pressure with adrenalin soaked gauze and Macgills forceps
- Urgent ENT consult
What is Ludwigs angina and list some risk factors
Rapidly progressive gangrenous bilateral cellulitis of the submandibular space with risk of life threatening airway compromise. Can spread pharyngomaxillary, retropharyngeal and to mediastinal
RISK FACTORS
Poor dentition and/or recent dental procedure (70% odontogenic origin)
DM
Alcohol abuse
IVDU
Malnutrition
HIV/AIDS
What are some signs of imminent airway compromise with Ludwigs angina
Inability to swallow
Stridor
Inability to protrude tongue
Increased resp distress or tripoding
Progressive exhaustion
Desaturation (late sign)
RSI has 50% failure rate and will need early tracheostomy or awake fiber optic with ENT
What are the organisms involved in Ludwigs angina and there treatment
Strep pneumonia, pyogenes and viridians
Staphy aureua
Fusobacterium
Anaerobes
Gram negative rods
Usually polymicrobial
Usually from dental infection (lower 2nd and 3rd molars most commonly)
Treatment
Benpen 50mg/kg (2.4g) QID with Metronidazole 12.5mg/kg (500mg) BD
OR
Augmentin 25mg/kg (1g) QID
OR
Clindamycin 15mg/kg (600mg) TDS
What is epiglottitis and how does it develop
Inflammation of epiglottis and adjacent supraglottic structures with can progress to life threatening airway
Usually infectious in origin, however non infectious causes such as caustic ingestion, thermal trauma or chronic granulomatous disorders (sarcoidosis, SLE)
Infection is due to bacteremia or direct invasion from posterio nasopharynx following microtrauma in viral illness or from swallowing
