ENT Emergencies Flashcards
What is important to check when a patient presents with nasal trauma
Deviation
Epistaxis
Nasal septum
Breathing
What are the complications of nasal trauma
CSF leak
Septal haematoma -> necrosis of cartilage
Epistaxis
Anosmia (loss of smell)
Why is it important to check the nasal septum when a patient presents with nasal trauma
To check for septal haematoma
What is septal haematoma
Bleeding under the perichondrium lining the septal cartilage, commonly caused by nasal trauma
Why is septal haematoma problematic
It stops blood supply getting to the septal cartilage since the cartilage gets its blood supply from the mucosa (the haematoma separates the mucosa and cartilage)
What can occur if septal haematoma is not treated early enough
septal perforation and necrosis
resulting in saddle-nose deformity
Management of septal haematoma
Urgent referral to ENT
Emergency incision & drainage
Management of suspected nasal fracture
Review nasal fracture in ENT clinic 5-7 days post-injury (if seen too early, it may not be visible)
Consider closed reduction if needed
Management for ear lacerations
Debridement
Closure under local anaesthetic
Cover with antibiotics if cartilage is exposed
What is CSF leak
Cerebral spinal fluid from the brain leaks through the cribriform plate and out of the nose
Symptoms of CSF leak
Headache
Persistent clear rhinorrhea
Management of CSF leak
Often settles spontaneously
Repair if does not resolve within 10 days
Do not give antibiotics initially
Causes of epistaxis
Idiopathic
Trauma
Foreign bodies
Tumour
Alcohol
Drugs (warfarin, aspirin, antiplatelets..etc)
Coagulopathy
Leukaemia
Thrombocytopaenia
Hereditary hemorrhagic telangiectasia
GPA
What drugs can cause epistaxis
Antiplatelets (clopidogrel, ticagrelor..etc)
Anticoagulants (warfarin, heparin, apixaban..etc)
Aspirin (both a NSAID and anti platelet)
NSAID
Examples of antiplatelets
Clopidogrel
Prasugrel
Ticagrelor
Examples of anticoagulants
Warfarin
Heparin
Apixaban
Rivaroxaban
Dabigatran
Apixaban, rivaroxaban and dabigatran are
DOAC - direct oral anticoagulants
Which has a higher bleeding risk - warfarin or DOAC
Warfarin
If a patient with epistaxis has hypertension, they are likely to
have prolonged bleeding
Where is the most common site of epistaxis
Kiesselbach’s plexus - at anterior septum
What are the arteries that contribute to the Kiesselbach’s plexus
anterior ethmoid
posterior ethmoid
sphenopalatine
great palatine
septal branch of superior labial
Sphenopalatine artery is a branch of
Maxillary artery
Greater palatine artery is a branch of
Maxillary artery (descending palatine branch)
Maxillary artery is a branch of
External carotid artery
Superior labial artery is a branch of
Facial artery
Facial artery is a branch of
External carotid artery
Anterior and posterior ethmoidal arteries are branches of
Ophthalmic artery
Ophthalmic artery is a branch of
Internal carotid artery
Name A-E
A- Anterior ethmoidal artery
B- Posterior ethmoidal artery
C- Septal branch of superior labial artery
D- Sphenopalatine artery
E- Greater palatine artery
Anterior bleeding of the nose is usually due to rupture of which vessels and what usually causes it
Anterior and posterior ethmoid arteries
mostly due to trauma
Posterior bleeding of the nose is usually due to rupture of which vessel and what usually causes it
Sphenopalatine arteries
Mostly due to underlying pathologies such as hypertension
Management of epistaxis
Take a brief history - ask about anticoagulants/antiplatelets
1. Direct compression of the cartilaginous part of nose, patient leaning forward, spitting out into a bowl, ice pack
2. Silver nitrate nasal cautery if there is a visible anterior bleeding point
3. Nasal packs or Foley catheters if bleeding point difficult to identify (posterior bleeding / heavy bleeding )
4. Sphenopalatine artery ligation for posterior bleeds
Why do patients with epistaxis need to pinch their nose while leaning forward
To prevent blood from entering the oral cavity / pharynx
Swallowing blood can cause vomiting and stomach irritation
When is nasal packing used for epistaxis
If it is posterior bleeding which is hard to identify
Heavy bleeding
When is sphenopalatine artery ligation indicated
Posterior bleeding
Uncontrollable severe bleeding
What is pinna haematoma
Perichondrial blood vessels tear due to trauma resulting in bleeding between the auricular cartilage and overlying perichondrium
Injury mechanicm of pinna haematoma
Shearing type injuries to the auricle e.g. in rugby players and boxers
What can pinna haematoma lead to
Disrupt blood supply to the cartilage -> avascular necrosis of pinna
-> Cauliflower deformity of the ear
Appearance of pinna haematoma
Management of pinna haematoma
Urgent aspiration, drainage, decompression of the haematoma within 24 hours of injury
Which bone of the base of the skull is the most commonly fractured
Temporal bone
Types of temporal bone fracture
Longitudinal
Transverse
The classification of longitudinal / transverse depends on
the relation of the fracture with the axis of the ear canal
Which type of temporal bone fracture is the most common
Longitudinal fracture
Injury mechanism of longitudinal fracture
Lateral blow to the head
Symptoms of basal skull fracture
Reduced consciousness
Battle’s sign - bruising of the mastoid
CSF leak
Epistaxis / bleeding from ear
Haemotympanum
Facial nerve palsy
What is Battle’s sign
Bruising over the mastoid process, indicating base of skull fracture
What is haemotympanum
Blood behind the tympanic membrane
Investigations for basal skull fracture
CT
Hearing test, facial nerve examination
Complications of longitudinal temporal bone fracture
Haemotympanum -> Conductive hearing loss
Disruption of ossicles -> conductive hearing loss
Facial palsy
CSF otorrhea (leak from ear)
Complications of transverse temporal bone fracture
Can cross the internal acoustic meatus and damage auditory and facial nerves
Sensorineural hearing loss
Facial palsy
Vertigo
Which type of temporal bone fracture more commonly presents with facial nerve palsy
Transverse fracture
For neck trauma, the neck is divided into
3 zones
What are the borders of zone 1 for neck trauma
From the sternal notch -> cricoid process
What structures are at risk of being damaged at zone 1
Trachea
Recurrent laryngeal and vagus nerves
Oesophagus
Subclavian artery and vein
Brachiocephalic vein
Proximal part of common carotid artery
Jugular veins
Spinal cord
What are the borders of zone 2 for neck trauma
Cricoid process -> angle of mandible
What structures are at risk of damage in zone 2
Larynx
Pharynx
Vagus nerve
Distal part of common carotid artery
Proximal part of internal and external carotid arteries
Jugular veins
Spinal cord
What are the borders of zone 3 of neck trauma
Angle of mandible -> base of skull
What structures are at risk of damage in zone 3
internal and external carotid arteries
Jugular veins
Cranial nerves IX - XII
Spinal cord
Investigations for neck injury
Ask mechanism of injury
Assess if there is any CNS problems
ABCDE
Haemodynamically stable ?
Management for patients with neck injury that are haemodynamically stable
CT angiogram -> surgical exploration / angiography / oesophagram / endoscopy / laryngoscopy
Management for patients with neck injury that are not haemodynamically stable
immediate surgery
What are deep neck space infections
When infections from the oropharyngeal region spreads into fascial planes
What are the 2 types of deep neck space infections
Parapharyngeal abscess
Retropharyngeal abscess
What is parapharyngeal abscess
When infection spreads to the space posterolateral to nasopharynx
What is retropharyngeal abscess
When infection spreads to the space anterior to pre vertebral fascia
Symptoms of deep neck space infections
Severe sore throat
Unwell
Neck stiffness
Trismus
Voice changes
Fever
What are the red flag symptoms for suspected DNSI patients that may indicate they can quickly decompensated
Severe neck pain or stiffness
Airway compromised - stridor/ drooling/ dyspnoea
Investigations for DNSI
Bloods - extremely high inflammatory markers
CT with IV contrast
Management for DNSI
IV antibiotics (broad spectrum) - co-amoxiclav/clindamycin
IV fluid resuscitation
Oxygen / intubation
Surgical drainage
What antibiotics are used for DNSI
Co-amoxiclav or clindamycin
