ENT Emergencies Flashcards by Joanne McEwan

what are the signs of nasal trauma?

bruising, swelling
tenderness
deviation (loss of C line)
epistaxis
infraorbital sensation
CNs

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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

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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

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name 4 possible complications of nasal fracture

epistaxis (mainly anterior ethmoid artery)
CSF leak
meningitis
anosmia (due to cribiform plate fracture)

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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

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where is epistaxis likely to occur from?

sphenopalatine artery
ethmoidal arteries
greater palatine artery

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how is a minor epistaxis managed?

local treatment
external pressure to nose
ice
cautery
nasal packing

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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)

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management of epistaxis if bleeding is controlled?

arrange admission if packed/poor social circumstances

FBC, G&S

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how is epistaxis managed if bleeding not controlled?

consider arterial ligation (SPA, ant ethmoid, external carotid)

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systemic epistaxis treatment?

reversal of effect of anticoagulants
correction of clotting abnormalities
platelet transfusion
treatment of hypertension

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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

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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

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how is pinna haematoma managed?

aspirate
incision and drainage
pressure dressing
no good evidence which technique is best

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pinna haematoma is also known as?

sub-perihondrial haematoma

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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)

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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