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N&SS - ENT > ENT Emergencies > Flashcards

ENT Emergencies Flashcards

1
Q

Where do most nose bleeds arise from?

A

Little’s area on the anterior nasal septum, from the arteries making up the Kiesselbach plexus.

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2
Q

Which arteries make up the Kiesselbach plexus?

A 
Anterior Ethmoid
Posterior Ethmoid
Sphenopalatine
Great Palatine
Superior Labial
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3
Q

What local factors may cause epistaxis?

A
  • Trauma - nose picking, nasal fracture, repeatedly blowing nose
  • Drug induced - nasal sprays, anticoag/aspirin
  • Foreign body
  • Rhinitis
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4
Q

What systemic factors may cause epistaxis?

A
  • Clotting disorders
  • HTN
  • Vasculitis
  • Hereditary haemorrhagic telangiectasia
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5
Q

How should we manage epistaxis?

A

ABCDE!! If horribly acute, but still ensure airway clear first:

  • Sit pt forward and upright, pinch soft part of bridge of nose
  • Get pt to spit blood out through mouth
  • IV access, bloods, G&S as appropriate (recurrent or severe nosebleeds)
  • Monitor pulse and BP for signs of shock/hypovolaemia
  • Cautery with silver nitrate if bleeding vessel is visible
  • If cautery fails, use nasal packing.
  • If posterior bleed, try balloon catheter.
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6
Q

What is the last thing we can try to stop epistaxis?

A

Surgical ligation of sphenopalatine artery.

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7
Q

How many nosebleeds are posterior in origin?

A

Only about 5%

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8
Q

Which origin of a nosebleed is potentially more serious? Why?

A

Posterior - usually more profuse and have a greater risk of airway compromise.

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9
Q

Are all nose-bleeds an emergency?

A

No - most people just deal with them and they resolve spontaneously. We usually see the ones that won’t resolve.

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10
Q

A pt comes in with recurrent nosebleeds. O/E, the nasal spetum looks sloughed and atrophic. Which part of the hx should you make sure you ask?

A

Illicit drug use, specifically inhaled drugs such as cocaine.

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11
Q

Does the presence of undiagnosed HTN following a nosebleed mean that the nosebleed is due to the HTN?

A

No - the rate of undiagnosed HTN is the same in the general population as in those who present with nose bleeds.

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12
Q

What is more suspicious - bleeding from either nostril repeatedly, or bleeding from the same nostril repeatedly? Why?

A

Bleeding from the same nostril repeatedly - may indicate malignancy.

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13
Q

How can you work out from the hx without examination where the bleed is in the nose?

A

Ask if blood is coming form one nostril and running out of the nose, or coming out of both nostrils and running down the throat.

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14
Q

Why do we need to ask about other H&N symptoms in recurrent epistaxis? What should we ask?

A

In case of nasopharyngeal tumours.

Facial pain
Otalgia
Nasal obstruction
Anosmia

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15
Q

What are the investigations of choice for suspicion of malignancy causing recurrent/severe nosebleeds?

A

CT scan and/or nasopharyngoscopy

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16
Q

What emergency might occur involving the outer ear?

A

Auricular/pinna haematoma

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17
Q

What is auricular haematoma?

A

A collection of blood between the cartilage of the ear and overlying perichondrium

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18
Q

When do we usually see auricular haematomas?

A

On contact sport players (usually rugby) or those who have had trauma to the head.

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19
Q

Why is an auricular haematoma an emergency (sort of)?

A

The blood collecting can disrupt blood supply to cartilage which if left untreated can cause avascular necrosis.

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20
Q

What is the consequence of untreated auricular haematoma, and how can we treat it to prevent this?

A

Cauliflower ear deformity.

Prompt drainage of the haematoma.

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21
Q

How does an auricular haematoma present?

A

Tender anterior auricular swelling following trauma, causing distorsion of pinna. Usually within 7 days of the trauma coccuring.

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22
Q

When is it too late to drain a pinna haematoma?

A

If the haematoma is oler than 7 days.

If this is a recurrent/chronic problem.

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23
Q

Who is nasal foreign body most common in?

A

Preschool children

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24
Q

What might a child have stuck up their nose or in their ear?

A 
Bead
Button
Sweets
Nuts
Seeds
Peas
Cotton bud
Insects
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25
Q

How might a nasal foreign body present?

A
  • Immediately if observed
  • Hx of nasal obstruction
  • Late with persistent offensive discharge from one nostril
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26
Q

How should nasal foreign body be managed?

A

ABCDE if its causing airway/breathing difficulties.

  • Topical anaesthetic and vasoconstrictor spray to reduce swelling
  • Blow positive pressure through the nose (usually block unobstructed nostril then parent blows through mouth)
  • Use nasal speculum and thin forceps
  • Be careful not to push it backwards
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27
Q

Which object is the worst object ever to get stuck in the nose, or ear, or be swallowed? Why?

A

Button battery - moisture in cavity with alkaline battery can cause huge amounts of tissue damage by liquefactive necrosis.

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28
Q

What is a complication of a nasal foreign body that also counts as an emergency sometimes?

A

septal perforation

29
Q

How might a pt present with an ear foreign body?

A
  • Pain
  • Deafness
  • Discharge
  • Buzzing (live insect)
30
Q

How should an ear foreign body be managed?

A

Carefully!! Don’t want to push the object further into the ear or damage the ear canal.

Kill insects first with 2% lidocaine.

Forceps/hook or irrigation or suction with a small catheter is often effective.

Easiest to do with ear canal straightened (pull pinna posteriorly).

31
Q

What is an emergency complication of otitis externa?

A

Necrotising/malignant otitis externa

32
Q

What is necrotising/malignant otitis externa?

A

Extension of otitis externa into the mastoid and temporal bones

33
Q

Who does necrotising/malignant otitis externa usually affect?

A

Elderly patients with diabetes or who are immunocompromised.

34
Q

What symptoms would suggest necrotising/malignant otitis externa over regular, run o’ the mill otitis externa?

A
  • Pain/headache which is worse than you would expect
  • Facial nerve palsy
  • Oedema
  • Exudate
  • Granulation tissue
35
Q

How should suspected necrotising/malignant otitis externa be investigated?

A

Swabs for culture for abx sensitivity.

Check for tympanic membrane integrity.

36
Q

How should suspected necrotising/malignant otitis externa be managed?

A

Oral cipro for 6-8 weeks.
Surgery may be considered.
Admit if pt unwell.

37
Q

Which organism usually causes necrotising otitis externa?

A

Pseudomonas

38
Q

What should happen with any patietnw with a severe sore throat not tolerating oral fluids?

Why?

A

Refer for urgent assessment.

Could be epiglottitis.

39
Q

What is epiglottitis?

A

Inflammation of epiglottis, potentially causing life-threatening complete airway obstruction.

40
Q

What is the most common cause of epiglottitis in children, and why is this so rare?

A

Haemophilus Influenzae type B.

Rare due to introduction of Hib vaccine.

41
Q

An adult comes in with severe sore throat and inability to tolerate oral fluids. What may be going on in the background to cause this presentation?

A

Underlying immunodeficiency or immune suppression.

42
Q

What is the most common cause of acute epiglottitis in adults?

A

Streptococcus spp.

43
Q

A patient with a H+N cancer who is starting chemotherapy comes to A+E with severe sore throat and new inability to tolerate oral fluids. What might be going on?

A

Acute reactive epiglottitis to chemotherapy

44
Q

What are the classic symptoms of acute epiglottitis?

A
  • Sore throat
  • Odynophagia
  • Drooling/inability to swallow secretions
  • Hot potato voice
  • Fever
45
Q

What features would indicate more severe epiglottitis?

A
  • Dyspnoea
  • Dysphagia
  • Dysphonia
  • Respiratory distress
  • Stridor
46
Q

How should suspected acute epiglottitis be investiagted?

A

Direct visualisation of larynx by flexible laryngoscopy.

DO NOT EXAMINE THROAT WITH TONGUE DEPRESSOR DUE TO RISK OF LARYNGEAL OBSTRUCTION.

47
Q

How is acute epiglottitis managed?

A

Conservatively - IV or oral abx, may need intubating to protect airway.

48
Q

If a patient with acute epiglottitis cannot be intubated, what is the next best way to secure the airway?

A

Surgical tracheostomy

49
Q

What is the most common complication of acute epiglottitis?

A

Absces formation - occurs in up to 25% of cases.

50
Q

Other than abscess formation, what complications can occur secondary to acute epiglottitis?

A
  • Meningitis
  • Sepsis
  • Pneumothorax
  • Pneumo-mediastinitis
51
Q

Why can mastoiditis occur?

A

The mastoid bone contains multiple air cells that come off the main antrum into which infection can spread from the middle ear.

52
Q

Which structures are located near to the mastoid antrum?

A 
Petrous temporal bone
Middle and posterior cranial fossa
Facial nerve
Sigmoid sinus
Lateral sinus
53
Q

A child who had symptoms of an ear infection comes to A+E due to new onset unilateral protrudence of the ear. What is the most concerning differential diagnosis?

A

Mastoiditis

54
Q

Despite mastoiditis being rare now, why is it on the rise?

A

Antibiotics - restrained use in AOM, inadequate dosing, and choice of abx.

55
Q

What risk factors are there for mastoiditis?

A
  • Age - children age 6-13 months (peak)
  • Immune compromise
  • Pre-existing cholesteatoma
56
Q

What is the most common organism isolated in acute mastoiditis?

A

Strep. pneumoniae

57
Q

How does mastoiditis present on examination?

A

Red tender boggy swelling/mass behind the ear.
Causes external ear to protrude forwards.
TM bulging or perforated
Pt is generally unwell

58
Q

A child presents with mastoiditis. What are the minimum investiagtion that should be done?

A
  • Blood cultures
  • CT/MRI to check for intracranial complications
  • LP if signs of intracranial spread
59
Q

How is mastoiditis managed?

A
  • High-dose broad-spec IV abx for 1-2 days, then continue on oral abx for 1-2 weeks
  • Supportive - analgesia, fluids
  • Fluid/collection drainage if needed
60
Q

What is the best antibiotic therapy for mastoiditis?

A

3rd gen cephalosporin e.g. cefixime/ceftriaxone/ceftazidime

61
Q

What emergency can acute tonsillitis cause?

A

Peritonsillar abscess

62
Q

What is a peritonsillar abscess?

A

Pus trapped between the tonsillar capsule and the lateral pharyngeal wall.

63
Q

Is peritonsillar abscess always preceeded by tonsillitis?

A

No - can sometimes occur with no obvious precursor infection, usually in smokers.

64
Q

Which organisms cause peritonsillar abscess?

A

Mixed flora usually.

Strep pyogenes is most common.

Staph aureus, H influenzae and anaerobic organisms.

65
Q

A child is brought to A+E with a history of tonsillitis, having started drooling and difficulty swallowing. O/E the uvula is deviated to the left. What other symptoms might this child have?

A
  • Fever
  • Foul-smelling breath
  • Trismus
  • Hot potato voice
  • Earache
  • Neck stiffness
  • Headache
66
Q

How is a peritonsillar abscess investiagted?

A

The diagnosis is made clinically so generally no further investigation is needed.

67
Q

How should pertonsillar abscess be managed?

A

Urgent referral to ENT

  • IV fluids as needed
  • Analgesia
  • IV abx
  • Surgical - aspiration/incision and drainage
68
Q

Why is it important that an ENT expert drains a peritonsillar abscess?

A

Location of internal carotid artery - risk of massive haemorrhage due to accidental iatrogenic injury.

N&SS - ENT (7 decks)

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