ENT Flashcards
describe the injury and management steps
Injury:
Auricular haematoma to the right pinna with small skin tear
negatives - no involvement of tragus
management:
analgesia
drainage
check for damage to other aspects of ear
block pinna
pressure dressing after
ADT
follow up
list the indications for surgical review of this injury?
What are contraindications to ED drainage?
- large overlying skin avulsion
- severe crush injury
- complete or near amputaiton/avulsion
- large cartilage defect
- devitalization of tissue
- large haematoma
Contraindications:
over 7/7 haematoma
recurrent haematoma
What is the diagnosis and three supportive findings?
Acute suppurative otitis media
- Bulging TM
- Erythematous TM
- pus behind TM
What are the options for analgesia?
paracetamol 15mg.kg
ibuprofen 10mg/kg
IN fentanyl 1.5mcg/kg
what are the indications for antibiotics?
Prior hearing impairment
Failure of conservative Rx (ie worsening Symptoms at 48hrs)
Cochlear Implant
Immunosuppression
List four methods and pros and cons of removing ear foreign body
Method - suction catheter
Pros - soft and atraumatic
Cons - nosy
Method - alligator forceps
Pros - not noisy
Cons - difficult to grip small objects and may cause trauma
Method - wax curette/bent paperclip
Pros - good for smooth objects to get behind
Cons - risk of trauma or pushing deeper
Method - irrigation or syringing
Pros - can flood out loose objects
Con - cant use if grommets or perforation
Method - refer to ENT
Pros - little risk to ED
Cons -
with epistaxis, what are key features in a history?
- estimate amount of blood loss eg duration, volume
- effects of blood loss - dizziness, collapse
- co-morbidities eg uncontrolled hypertension
- reason for anticoagulation if reversal is needed
- social situaiton - can they manage at home
- other meds - to increase bleeding
- ?trauma
What are the steps for controlling untraumatic epistaxis
- first aid- sit up lean forward and squeeze
- suction clots and blood
- topical constrictor eg adrenaline or co-phenylcaine
- cautery eg nitrate sticks
- optimise anticoag
- rapid rhino
list three pieces of advice for epistaxis on discharge
- general - do not pick or blow nose for 4/7, moisturise nostrils
- see GP for anticoag FU
- when to return - on going bleeding not controlled with first aid or needing pack removal
what are the causes of epistaxis in adult patient
alcohol
htn
bleeding disease eg VWD
meds - antiplatelets
recreational drugs eg cocaine
trauma
neoplasm eg SCC
what are the features concerning for a malignant cause of epistaxis?
- Unilateral nasal blockage +/- discharge
- Local oral features – eg ill-fitting dentures or loose teeth and buccal soft tissue swelling
- Localised lymphadenopathy
- Hearing loss
- Trismus
- Neuralgia
- Risk factors for nasopharyngeal malignancy - alcohol, tobacco, race – SE Asian, Chinese
predominance
What are the specific managements for posterior epistaxis?
- posterior cauterisation under GA
- arterial ligation
- local injection of lidocaine and adrenaline around sphenopalantine artery
- embolisation via femoral artery under IR
what are the relevant features of this x ray
radio opague FB in oesophagus - likely coin
it is below laryngeal inlet and not obstructing trachea
Likely diagnosis?
What are the anatomical structures involved?
what is the approach to imaging?
bilateral TMJ dislocation
mandibular condyle moves anteriorly out of mandidular fossa
imaging:
spontaneous - none
traumatic - CT
What is the approach to managing TMJ dislocation?
syringe technique -
10ml syringe place between maxillary and mandibular molars and roll back and forth awaiting reduction
manual reduction-
using gloves place thumb on mandibular molars and firm constant pressure inferioposteriorly until reduction
what are the discharge instructions post tmj relocation
- Simple analgesia – paracetamol / ibuprofen
- Soft / liquid diet
- Avoid yawning / taking large bites
- if recurrent, maxillofacial review
What are the features of occult nasal FB in kids?
- unilateral epistaxis
- unilateal blockage
- foul smell
- unilateral nasal breathing
- septal necrosis
What equipment is used in nasal FB extraction
topical anaeasthetic and vasoconstrictor
airway equipment incase of obstruction
nasal speculum
head torch
PPE
forceps
with nasal FB what are the indications for referral to surgeon?
posterior or not easily visualised
chronic or impacted with marked inflammation
penetrating or hooked FB
failure to remove eg bleeding, uncooperative patient
name three methds for nasal FB removal and pros and cons
Method - direct instrumentation eg forceps or hooks
Pros - useful if object easily visualised
Cons - may not be able to grasp, may pusch deeper
Method - suction catheter
Pros - can remove anterior things and blood/mucours
Cons - loud
Method - positve pressre eg mothers kiss or blowing out one nostrol
Pros - easy if coooperate and can sooth child
Cons - needs cooperation and may be difficult for larger objects
what are the complications of nasal FB?
mucosal necrosis
aspiration
sinus infection
what are the options for ensuring child is cooperative?
GA
physical restraint
procedural sedation
with nasal FB would would suggest need for bronchoscopy?
stridor
unilateral wheeze
hypoxia
coughing and choking
what are the differentials for neck lump?
What investigations may help diagnose?
HL or NHL
EBV
bacterial tonsilitis
reactive lymph node
hyperthyroidism
what clinical features are used to assess severity of upper airway obstruction?
nature of stridor eg continuous or not
self positioning - relaxed or upright
?swallow secretions
?hot potato voice
respiratory distress
anxiety
how do you manage acute upper airway obstruction eg quinsy
keep sitting up
keep calm
IV hydrocortisine 200mg
IV abx ceftriaxone 2g
nebulsed adrenaline
involved ENT early
difficult airway equipment to bed
What are the considerations needed when transferrings someone with airway compromise?
Patient- severty, difficulty of airway, response to treatment
Equipment - airway equipment, drugs
Escort - senior doctor
Distance - road v air - plan for deterioration
Describe injury
large zig zag shaped would
penetrates platysma
evidence of blood soaked gauze
soft tissue swelling at mandible
face not involved
List the indications for emergent intbation of someone with penetrating neck injury
stridor
acute resp distress
profound shock
altered mental state
expanding haematoma
airway obstruction from blood or secretions
list differentials and features that would suggest that
chronic supparative otitis media
meningits - photophobia, rash
mastoiditis - boggy swelling over mastoid
encephalitis - confusion
cerebral abscess - ataxia, cerebellar signs
cholesteatoma
with strangulation what features or in the history suggest further investigtion
hoarse voice
ligature marks
LOC
haematoma/petichial rash
carotid bruit
dyspnoea
what are the differentials for stridor in kids
croup
laryngomalacia
laryngeal FB
epliglottis
bacterial tracheitis
retropharyngeal abscess
what are the indications for intubation with stridor?
exhaustion
type 1 failure
type 2 failure
reduced level of consciousness
What is the intubation equipment for a child
Bag Valve Mask (with size - child)
Laryngoscope with Miller blade (size 2) and Macintosh blade (size 2)
ETT 4.0-4.5 and one size below due to anticipated laryngeal oedema
Bougie
Suction
Laryngeal Mask Airway (size 2)
Surgical airway equipment – needle cricothyrotomy
Ketamine 2mg/kg or Fentanyl 2-5 mcg/kg or Propofol 1-2 mg/kg
Suxamethonium 1-2 mg/kg or Rocuronium 1.2 mg/kg
what is the radiographical sign of epiglottitis?
What is the usual causative agent and treatment?
thumb printing
strep pneumonae. ceftriaxone 1g
epiglottis and intubation
factor, anticipated problem and solution
What is this?
Why
large unilateral swelling below mandible with surrounding erythema
ludwigs angina (submandibular abscess)
what is the management of ludwigs angina
analgesia eg fentanyl
iv abx - metro and benpen
urgent ent/max fax review for drainage or airway support
what are the initial management steps of a post tonsillectomy bleed?
2 large iv cannula
bolus nacl at 20ml/kg
o neg blood
aim for pulse under 120 and bp over 90
with a post tonsillectomy bleed what intubation difficulties may you experience and how will you prepare?
what are four methods for reducing bleeding in post tonsillectomy blood
ice gargles
co-phenylcaine spray
adrenaline soaked gauze
packing
what are the risk factors for TMJ dislocation?
previous tmj dislocation
CTD eg ehlor danlos
prior TMJ trauma
what mechanisms can cause TMJ dislocation?
seizures
trauma
yawning/screaming
iatrogenic eg dental procedures
* dystonic drug reaction
