ENT Trauma Flashcards
Mechanisms of injury with nasal trauma?
Fight, sports and falls
Important Hx questions with nasal trauma?
When did it occur?
Was there a loss of consciousness? - suggests head injury
Epistaxis?
Breathing issues?
Symptoms and signs of nasal trauma?
Bruising, swelling and tenderness
Deviation
Epistaxis - if this is recurrent, it suggests an arterial injury
Facial tenderness
Check infraorbital sensation and CN functions
What is a nasal septal haematoma?
Assoc. with nasal septal trauma; blood separates the septal cartilage and the perichondrium (which provides nutrition to the cartilage)
Although septal hematomas are rare, early diagnosis and treatment is important to prevent abscess formation, septal perforation, saddle-nose deformity, and potentially permanent complications
Why must septal haematomas be excluded and treated early?
If not treated:
• Abscess formation
• Intracranial infection
• Septal perforation and saddle-nose deformity
Examination of a septal haematoma?
If boggy when prodded, it may be a septal haematoma
If solid, it is likely to be a deviated septum
Examination of a nasal fracture?
Clinical diagnosis that is based on deviation/cosmesis and breathing issues
Review at 5-7 days post-injury (once swelling has settled)
Management of nasal fracture?
Various options:
• No intervention
• Manipulation under anaesthetic (MUA) - local or general
Complications of nasal fracture?
Epistaxis (part. if the anterior ethmoid artery has been injured)
CSF leak (risk of ascending infection leading to meningitis)
Fracture of the cribriform plate can cause anosmia
Treatment of CSF leak due to nasal fracture?
Tends to resolve spontaneously (dura heals itself); if not healed within 10 days, repair
Prophylactic antibiotics are not given as risk of infection is low; antibiotics are only given if symptoms of meningitis develop
Vasculature of the nose?
Just underneath the mucosa and arteries include:
• Anterior and posterior ethmoid arteries
• Sphenopalatine artery
• Greater palatine artery
Mx of epistaxis in relation to stopping bleeding?
If necessary, resuscitate
Arrest/slow blood flow with:
• Pressure
• Ice
• Topical vasoconstrictor +/- LA (lignocaine + adrenaline, co-phenylcaine)
Remove clot:
• Suction
• Nose-blowing
Cautery/pack (AKA nasal tampon)
Rigid nasendoscopy can be used
Cauterise vessel:
• Silver nitrate (if there is no active bleeding to stop the chemical sliding off)
• Diathermy
Consider arterial ligation
Ix for epistaxis?
FBC (assess haemorrhage)
Cautions with epistaxis and risk of aspiration of blood?
Do not sedate the patient
How does a pinna haematoma form?
AKA sub-perichondrial haematoma
Trauma, e.g: boxing, can lead to separation of the anterior auricular perichondrium from the underlying cartilage; there can be tearing of the perichondrial blood vessels and haematoma formation
Treatment of a sub-perichondrial haematoma?
Various techniques:
• Aspiration
• Incision and drainage
• Pressure dressing
Causes of lacerations pinna?
Blunt trauma, avulsion, dog bites, etc
Mx of lacerations to the pinna?
Debridement and closure:
• Primary OR reconstruction
Pinna has a very good blood supply so can heal if reattached
Usually, LA is given and antibiotics (prevent cartilage infection)
Hx questions in a temporal bone fracture?
Injury mechanisms and assoc. injuries
Other symptoms: • Hearing loss • Facial palsy • Vertigo • CSF leak
Examination of temporal bone fracture reveals?
Occasionally, a battle sign (bruising behind the ear) can be seen
Check condition of the TM and ear canal; check function of CN VII
Do a hearing test
Classifications of temporal bone fractures?
Longitudinal (80%) VS transverse fractures (20%)
Otic capsule involved VS otic capsule spared
Describe longitudinal temporal bone fractures?
Typically caused by lateral blows, resulting in a fracture line that parallels the long axis of the petrous pyramid
Symptoms and signs of longitudinal fractures of the temporal bone?
Bleeding from external canal (laceration of skin and ear drum)
Haemotympanum and ossicular chain deafness (causes conductive deafness)
Facial palsy may occur
Otorrhoea of CSF
Describe transverse fractures of the temporal bone
Typically caused by frontal blows, resulting in a fracture at right angles to the long axis of the petrous pyramid
Symptoms and signs of transverse fracture?
Fracture can cross internal acoustic meatus and damage the auditory and facial nerves
Sensorineural hearing loss (damage of CN VIII)
Facial nerve palsy (half of patients)
Vertigo
4 types of hearing loss?
- Conductive
- Sensorineural
- Mixed
- Central
Causes of conductive hearing loss?
Fluid
• Blood (looks blue)
• Effusion (golden)
• CSF leak
TM perforation
Ossicular problem
Stapes fixation (AKA otosclerosis) - stapes is fixed in the oval window and so cannot vibrate
Causes of sensorineural hearing loss?
Sensory (cochlea)
Neural (CN VIII)
Mx of temporal bone fractures?
Often delayed due to polytrauma
May require:
• Facial nerve decompression (if they have no recovery and EMG studies are +ve, as these suggest a laceration rather than compression)
• Management of CSF leak
• Hearing restoration (hearing aid or ossiculoplasty)
How to differentiate the severity of nerve injuries?
If nerve injury occurred at the time of injury and symptoms started then, likely that the nerve was lacerated
If nerve injury occurred a few days later with symptoms developing at this time, likely that allowing the nerve to decompress will resolve symptoms
Causes of neck trauma?
Penetrating (knife, gunshot, RTA, industrial/household accidents)
Blunt (RTA, sports injuries)
Occurrence of neck trauma?
More common in males, adolescents/young adults
Depends on city
What does a zone 1 neck injury involve?
Zone 1: - involves: • Trachea and oesophagus • Thoracic duct • Brachiocephalic, subclavian, common carotid and thyrocervical vessels • Spinal cord
What does a zone 2 neck injury involve?
Zone 2 - involves: • Larynx and hypolarynx • CN X, XI, XII • Carotid and internal jugular vessels • Spinal cord
What does a zone 3 neck injury involve?
Zone 3 - involves: • Pharynx • CNs • Carotid, internal jugular and vertebral vessels • Spinal cord
Hx questions with a neck injury?
Mechanism?
Pain (SOCRATES)?
Aerodigestive tract symptoms:
• Dyspnoea, hoarseness, dysphonia, haemoptysis
• Dysphagia
CNS issues (paraesthesia and weakness)?
Examination of neck injury?
ABCDE
Secondary survey
What does the secondary survery involve?
Inspect the injury:
• If injury has not gone through the platysma, it can be cleaned and closed
• If through platysma, must explore and deal with it as a true penetrating wound
Zone of neck
Bleeding/haematoma
Aerodigestive injuries
Neurological assessment
What is the platysma?
Superficial muscle that overlaps the sternocleidomastoid
Ix of neck injuries?
FBC, G
CXR (may show haemothorax or emphysema)
CT angiogram
MRA
Complications of neck injuries?
Expanding haematoma
Hypovolaemic shock
Airway obstruction
Blood in aerodigestive tract
What is the maxilla?
Bridge between the cranial base and dental occlusal plane (functionally and cosmetically important)
Cause of maxillary fracture?
High-energy blunt force injury to the facial skeleton; potentially life-threatening and disfiguring
Sign of maxillary fracture?
“Bite” (dental occlusion) feeling abnormal
Occurrence of orbital floor fractures?
2nd most common mid-facial fracture
Main area in which orbital floor fracture occur?
Infraorbital groove
Signs of orbital floor fracture?
Pain
Decreased visual acuity and diplopia
Hypoaesthesia in infraorbital region
Periorbital ecchymosis (racoon eyes) and oedema
Enophthalmos
Restriction of ocular movement
Bony step of orbital rim
Ix for orbital floor fracture?
CT sinuses shows “tear drop” sign
What is an orbital blowout fracture?
Affects the medial wall and floor
Mx of orbital floor fractures?
Conservative
Surgical repair of bony walls if:
• Entrapment
• Large defect
• Significant enophthalmos
Le fort classification of fractures?
Le fort I - horizontal and passes above the teeth apices
Le fort II - pyramidal
Le fort III - transverse
Surgery for vertical buttresses?
Reduce the fracture and fixate
