ENT emergencies Flashcards
what information is required in the history of someone with nasal trauma?
History -Mechanism of injury -Fight, sport, falls When LOC Epistaxis Breathing
what is seen in the examination of someone with nasal trauma?
Bruising, Swelling Tenderness Deviation Epistaxis Infraorbital sensation CNs
what is important to exclude when handling nasal traumas always?
septal haematoma
how can nasal fractures be diagnosed?
clinically without investigations as they are unnecessary
based on deviation/cosmesis and breathing
when should you review someone with a nasal fracture in ENT clinic?
5-7 days post-injury
when should you consider digital manipulation in someone with a nasal fracture?
< 3 weeks
what are the complications of nasal fractures?
Epistaxis – particularly ant ethmoid artery
CSF leak , meningitis
Anosmia – cribriform plate fracture
what percent of the population will experience an episode of epistaxis each year?
5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those seeking medical care will need a specialist.
why is the nose prone to epistaxis?
Vascular organ secondary to incredible heating/humidification requirements
Vasculature runs just under mucosa (not squamous)
Arterial to venous anastamoses
ICA and ECA blood flow
what blood vessels cause epistaxis?
sphenopalatine artery, ethmoid arteries, greater palatine artery
what is the first aid measures when dealing with epistaxis?
Local Treatment External Pressure to Nose Ice Cautery Nasal Packing
what is the further management of epistaxis?
Resuscitate on arrival if necessary
Arrest/slow flow: pressure, ice, topical vasoconstrictor +/- LA (Lignocaine + adrenaline, Co-phenylcaine)
Remove clot: suction, nose blowing
Anterior Rhinoscopy
Cautery / pack
300 rigid nasendoscopy
Cauterise vessel: silver nitrate / diathermy
if the bleeding in epistaxis is controlled?
Arrange admission if packed/poor social circumstances
FBC, G&S
Please don’t consider sedation
what if the bleeding isn’t controlled in epistaxis?
Consider arterial ligation (SPA, Ant ethmoid, external carotid)
what is the systemic treatment of epistaxis?
Reversal of effect of anticoagulants
Correction of clotting abnormalities
Platelet transfusion
Treatment of hypertension
what is a CSF leak?
A CSF leak is a condition that occurs when the CSF leaks through a defect in the dura or the skull and out through the nose or ear.
A CSF leak results from a hole or tear in the dura, the outermost layer of the meninges. Causes of the hole or tear can include head injury and brain or sinus surgery. CSF leaks may also occur after lumbar puncture, also called a spinal tap or spinal anesthesia. Spontaneous CSF leaks can also occur for no known reason.
how to manage CSF leaks?
often settles spontaneously - need repair if not within 10 days
what could be a site of fracture for CSF leaks?
cribriform plate
what is the roe of antibiotics in treatment of a CSF leak?
not clear - ascending infection
what are ear emergencies?
Pinna Haematoma
Ear Lacerations
Temporal bone fractures
Sudden sensorineural hearing loss
what is a pinna haematoma?
it is a sub-perichondria hematoma.
Shearing forces to the auricle can lead to separation of the anterior auricular perichondrium from the underlying, tightly adherent cartilage. As a result, there can be tearing of the perichondrial blood vessels and subsequently a hematoma formation.
treatment of a pinna hematoma?
Aspirate
Incision and drainage
Pressure dressing
No good evidence which technique is best.
what can cause ear lacerations?
Blunt trauma
Avulsion
Dog bites
Tissue loss
what is the management of ear lacerations?
Debridement Closure Primary Reconstruction Usually LA Antibiotics - cartilage
what to ask for in the history of someone with temporal bone fractures?
Injury mechanism Hearing loss Facial palsy Vertigo CSF leak Associated injuries
what do you see in the examination of someone with a temporal bone fracture?
Bruising – Battle sign
Condition of TM and ear canal
VII
Hearing test
how can you classify temporal bone fractures?
Longitudinal vs transverse
Otic capsule involved
Otic capsule spared
what percent of temporal bone fractures are longitudinal fractures?
80%
what is the cause of longitudinal fractures?
lateral blows
what is a longitudinal fracture?
Fracture line parallels the long axis of the petrous pyramid
Bleeding from external canal due to laceration of skin and ear drum
what are the complications from longitudinal fractures?
Haemotympanum (conductive deafness)
Ossicular chain disruption (conductive deafness)
Facial palsy (20%)
CSF otorrhoea
what percent of temporal bone fractures are transverse fractures?
20%
what is the cause of transverse fractures?
frontal blos
what is a transverse temporal fracture?
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
what are the complications of transverse fractures?
Sensorineural hearing loss due to damage to 8th cranial nerve
Facial nerve palsy (50%) & Vertigo
what causes conductive hearing loss?
fluid?
TM perforation
ossicular problem
what is the management of conductive hearing loss?
Often delayed as polytrauma
May need facial nerve decompression , If no recovery and EMG studies
May need to manage CSF leak , most settle but may need repair
May need hearing restoration, Either hearing aid or ossiculoplasty
how to test for sudden sensorineural hearing loss?
weber test
what is the treatment for sudden sensorineural hearing loss?
steroids
foreign bodies in ear:
Can usually wait until urgent clinic for removal
Except watch batteries – remove immediately
Live animals – drown with oil can be removed next day
what are the causes of neck trauma?
Penetrating : Knife / GSW / MVA Industrial accidents Household accidents Blunt MVA Sports injuries (clothesline tackle)
who tends to be susceptible to neck trauma?
Males > females, Adolescents and young adults
Glasgow second most violent city in UK
903 knife incidents last year
Penetrating trauma mortality rate 2-6%
which is the most common neck trauma seen?
ZONE I injury
what comprises a ZONE I neck injury?
Trachea Oesophagus Thoracic duct Thyroid Vessels – brachiocephalic, subclavian, common carotid, thyrocervical trunk Spinal cord
what comprises a ZONE II neck injury?
Larynx Hypoharynx CN 10,11,12 Vessels – carotids, internal jugular Spinal Cord
what comprises a ZONE III neck injury?
Pharynx
Cranial Nerves
Vessels – Carotids, IJV, Vertebral
Spinal Cord
what is essential in the history of someone with neck trauma?
Mechanism of injury
Pain - location, nature, intensity, onset, radiation
Aerodigestive tract - dyspnoea, hoarseness, dysphonia, dysphagia - haemoptysis
CNS problems - paraesthesias, weakness
what is should you look out for in the examination of someone with a neck injury?
A – airway (stridor, hoarseness) B – breathing (RR, accessory muscles) C – circulation (BP, HR, palpable pulse) D – disability E – full exposure
what is the secondary survey of neck injury?
Inspect ? through platysma Zone of neck Bleeding/haematoma Aerodigestive injuries Neurological – power, sensation upper arm
what investigations are useful in neck trauma?
FBC, G&S / XM AP/Lateral neck - ?FB CXR – haemo-pneumothorax, emphysema CT Angiogram – vascular, pseudoaneurysm, laryngeal, aerodigestive tract MRA
what is the management of neck trauma?
Urgent exploration – expanding haematoma, hypovolaemic shock, airway obstruction, blood in aerodigestive tract
Laryngoscopy, bronchoscopy, pharyngoscopy, and oesophagoscopy
Angiography – embolize, occlude
what is a deep neck space infection?
extension of infection from tonsil or oropharynx into deeper tissues
what is noted in the history of someone with a deep neck space infection?
sore throat, unwell, limited neck movement
what is seen in the examination of someone with a deep neck space infection?
Febrile, trismus, red / tender neck
what is the treatment of someone with a deep space neck infection?
Fluid resuscitation
Intravenous antibiotics
Incision and Drainage of neck space
regarding foreign bodies remember:
kids will swallow anything and so will adults
facial trauma?
Maxillary fractures
A bridge between the cranial base and the dental occlusal plane - functionally and cosmetically important structure
Fracture of these bones is potentially life-threatening as well as disfiguring
High-energy blunt force injury to the facial skeleton
what is the second commonest mid facial fracture?
orbital floor fractures
what causes orbital floor fractures?
Impact injury to globe
Large enough not to penetrate globe
Small enough not to fracture orbital rim
what is the weak point of the orbital floor?
infraorbital groove
what is noted in the history and examination of someone with an orbital fracture?
Pain, Decreased visual acuity, Diplopia Hypoaesthesia in infraorbital region Periorbital ecchymosis Oedema Enopthalmos Restriction of ocular movement Bony step of orbital rim
what are the investigations used to diagnose orbital floor fractures?
CT Sinuses
‘tear drop’ sign
Blow out fracture – medial wall and floor
what is the management of orbital floor fractures?
Conservative Surgical repair of bony walls if: Entrapment Large defect Significant enophthlamos
le fort fractures history
Mechanism of injury LOC & confusion Airway Vision Cranial nerves Dental Occlusion
Le fort fractures examination?
Soft tissue swelling Bruising & haematoma Posterior retrusion of the mid face Upper airway may be compromised Palpate - detect for bony irregularities, step-offs, crepitus, and sensory disturbances
what is the imaging of choice for le fort fractures?
CT
what is the treatment for le fort fractures?
reduce and fix
