ENT Emergencies Flashcards
what are the signs of nasal trauma?
bruising, swelling tenderness deviation (loss of C line) epistaxis infraorbital sensation CNs
what must be excluded in nasal trauma?
sub-perichondrial haematoma
- collection of blood between the cartilage of the nasal septum and the perichondrium
- can cause necrosis of cartilage as the nasal septum has no direct blood supply and gets all its nutrition from the perichondrium
- can cause abscess, infection etc
- medical emergency
how is a nasal fracture diagnosed and managed?
clinical diagnosis based on deviation and cosmesis
management
- check breathing
- review in ENT clinic 5-7 days post injury
- consider digital manipulation (reduce the fractured bone) in under 3 weeks
name 4 possible complications of nasal fracture
epistaxis (mainly anterior ethmoid artery)
CSF leak
meningitis
anosmia (due to cribiform plate fracture)
why is bleeding common in the nose?
vasculature runs just under the mucosa (not squamous epithelium like vasculature under external skin e.g - arms)
arterial to venous anastomoses
where is epistaxis likely to occur from?
sphenopalatine artery
ethmoidal arteries
greater palatine artery
how is a minor epistaxis managed?
local treatment external pressure to nose ice cautery nasal packing
how is more severe epistaxis managed in hospital?
resuscitate on arrival if needed
arrest/slow flow pressure (pressure/ice/topical vasoconstrictor +/- lignocaine + adrenaline/Co-phenylcaine
remove clot (suction and nose blowing)
anterior rhinoscopy
cautery/pack
30 degree rigid nasendoscopy
cauterise vessel (silver nitrate/diathermy)
management of epistaxis if bleeding is controlled?
arrange admission if packed/poor social circumstances
FBC, G&S
how is epistaxis managed if bleeding not controlled?
consider arterial ligation (SPA, ant ethmoid, external carotid)
systemic epistaxis treatment?
reversal of effect of anticoagulants
correction of clotting abnormalities
platelet transfusion
treatment of hypertension
what can cause a CSF leak and how is this usually managed?
can be due to fracture of cribiform plate
often settle spontaneously within 10 days
- if not then need repair
what is a pinna haematoma?
trauma to ear causes collection of blood between cartilage and perichondrium (nutrient supply to cartilage as no direct blood supply)
cartilage dies and shrivels and grows abnormally
results in cauliflower ear
how is pinna haematoma managed?
aspirate
incision and drainage
pressure dressing
no good evidence which technique is best
pinna haematoma is also known as?
sub-perihondrial haematoma
how is laceration to the ear managed?
debridement
closure (primary or reconstruction)
usually lignocaine + adrenaline
antibiotics (to prevent chondritis as microbes can access exposed cartilage)
what features may be associated with temporal bone fractures?
hearing loss facial palsy vertigo CSF leak associated injuries
what characteristic sign is seen in base of skull (e.g temporal) fracture?
brusing (Battle’s sign)
how are temporal bone fractures classified?
longitudinal vs transverse
otic capsule involved vs spared
what type of temporal bone fracture is most common and how does it occur?
longitudinal fracture
lateral blow to the head
features of longitudinal temporal bone fracture?
fracture line parallels the long axis of petrous pyramid
bleeding from external canal due to laceration of the skin and ear drum
haemotympanum (blood in middle ear behind the tympanic membrane - leads to conductive deafness)
ossicular chain disruption (conductive deafness)
facial palsy (only in 20%)
CSF ottorhoea
what causes a transverse fracture and what are the features of this?
frontal blows to the head
fracture at right angles to the long axis of the petrous pyramid
can cross the internal acoustic meatus causing damage to auditory and facial nerves
sensorineural hearing loss due to damage to 8th cranial nerve
facial nerve palsy (in 50%)
vertigo
what 3 things can cause conductive hearing loss?
fluid
TM perforation
ossicular problem
how are temporal fractures managed?
may need facial nerve decompression if no recovery and EMG studies
may need to manage CSF leak (however most settle)
may need hearing restoration (hearing aid or ossiculoplasty)
what is sudden sensorineural hearing loss?
hearing loss within 3 days of at least 30 decibels at 3 frequencies
- medical emergency
how is sudden sensorineural hearing loss managed?
test with Weber test
high dose steroids for 3 days
urgent referral to ENT
most foreign bodies in the ear can usually wait until urgent clinic for removal, what 2 things cannot wait?
watch batteries - must be removed immediately
live animals - drown with oil and can then be removed the next day
zone 1 injuries include injury to what areas?
trachea oesophagus thoracic duct thyroid vessels (brachiocephalic, subclavian, common carotid, thyrocervical trunk) spinal cord
what structures are included in zone 2?
larynx hypopharynx CN 10, 11, 12 vessels - carotids, internal jugular spinal cord
what structures are included in zone 3?
pharynx
cranial nerves
vessels - carotids, Internal jugular, vertebrals
spinal cord
what is the platysma?
broad sheet of muscle extending from the clavicle to the angle of the jaw
what investigations are required for a penetrating injury to the neck?
FBC, G&S/XM (if platysma penetrated)
AP/lateral neck imaging (look for foreign body)
CXR - haemo pneumothorax, emphysema
CT angiogram - vascular, pseudoaneurysm, laryngeal, aerodigestive tract
MRA
how is neck laceration managed?
urgent exploration - expanding haematoma - hypovolaemic shock - airwy obstruction - blood in aerodigestive tract laryngoscopy, bronchoscopy, pharyngoscopy and oesophagoscopy angiography - embolize, occlude
what is deep neck space infection and how does it present?
extension of infection from tonsil or oropharynx into deeper tissues ore throat unwell limited neck movement febrile trismus red/tender neck
what site of deep neck space infection is the most dangerous?
infection in the retropharyngeal space can track down and enter the mediastinum
how is deep neck space infection managed?
fluid resuscitation
IV antibiotics
incision and drainage of neck space
where is a solid foreign body likely to lodge in a child and how is it managed?
cricopharyngeus
AP and lateral imaging
urgent removal
what is the weak point of the orbit?
infra-orbital groove
how will an orbital fracture present?
pain, decreased acuity, diplopia hypoaesthesia in infraorbital region periorbital echhymosis oedema enopthalmos restriction of ocular movement bony step of orbital rim
how is orbital fracture investigated?
CT of sinuses - tear drop sign
blow out fracture - medial wall and floor of orbit
how is an orbital fracture managed?
conservative surgical repair of bony walls if - entrapment - large defect - significant enopthalmos
how is a le fort fracture managed?
reduce fracture and fix alone buttress lines
