surgery - ENT throat Flashcards
why are deep neck space infections serious?
patients rapidly deteriorate with airway compromise
how do deep neck space infections spread?
from the oropharyngeal region and into the fascial planes
what are the main types of deep neck space infections?
what organisms cause deep neck space infections?
Staphylococcus, anaerobes, and Gram-negative bacilli
how Is the cervical fascia divided anatomically?
superficial and deep fascia. The superficial fascia consists of skin, subcutaneous tissue and the platysma, whilst the deep fascia is further divided into superficial, middle and deep layers.
what is in the superficial layer of fascia?
The superficial layer (or investing layer) of the deep fascia covers the submaxillary and parotid glands as well as muscles deep to the platysma (the trapezius, sternocleidomastoid and strap muscles). This layer encloses the submandibular and masticator spaces, which can be a focus of dental or submandibular infections
what is in the middle layer of fascia?
The middle layer (or pretracheal layer) encloses the visceral organs of the neck, namely (from anterior to posterior), the thyroid and parathyroid glands, the larynx and trachea, the pharynx, and oesophagus.
what is in the deep layer of fascia?
The deep layer (or prevertebral layer) covers the vertebral column and the paravertebral muscles (Fig. 2). There is a potential space between the middle and deep layers anteriorly, termed the retropharyngeal space, which is subdivided by a thin membrane called the alar fascia. Posterior to the retropharyngeal space is the “danger space”, which extends from the oropharyngeal region inferiorly into the posterior mediastinum to the level of the diaphragm.
what is the parapharyngeal space?
The parapharyngeal space is a potential space on bilateral aspects of the neck, which is shaped like an inverted cone, bordered superiorly by the skull base and inferiorly by the hyoid bone. Medially it is bordered by the pretracheal fascia, and laterally by the superficial fascia. It is divided into anterior and posterior compartments by the styloid process and its attached muscles.
features of deep neck space infections?
severe sore throat, difficulty breathing, new-onset dysphagia or odynophagia, drooling, voice changes (such as hoarseness or voice loss), or neck stiffness
systemic signs of infection
stridor, trismus, pharyngeal swelling
cervical lymphadenopathy.
red flags for deep neck space infection?
what ix for deep neck space infection?
fibreoptic nasal endoscopy - assess airway latency and supraglottic structures
raised inflammatory markers
Blood cultures
CT neck with contrast
xray
mx for deep neck space infection?
broad spec abx
IV dexamethason
fluid resus
humidified oxygen with saline nebulisers
intubation
surgical mx of deep neck space infection?
surgical drainage (or sometimes radiological-guided) and washout
through the mouth or through the neck
what are red flags for foreign bodies?
how do you remove foreign bodies from ears?
array of instrumentation, such as microsuction with a Zoelner sucker, crocodile forceps, Jobson-Horne probes, or wax hooks
If the FB is medial against the tympanic membrane or simply it cannot be removed, patients can be safely discharged home with a view to removing the foreign body under general anaesthesia (unless a button battery in which case immediate removal is needed), whilst organic materials will often need urgent removal.
how do you remove foreign bodies from nose?
Nose FB management is similar to that for ear FB, however emergency removal under GA should be performed if the patient is distressed or any signs of breathing difficulty.
If unable to remove or unsure if the FB is present, consent and work-up for examination under anaesthesia and removal.
how do you remove foriegn bodies from throat?
If the FB is visualised in the oropharynx and the patient can tolerate the procedure, removal may be attempted using Magill forceps and laryngoscope, with adequate local anaesthetic.
Flexible nasendoscopy can be used to aid visualisation of the oropharynx whilst removing the foreign body. Otherwise, removal should be attempted with endoscopy under general anaesthesia (either via pharyngoscopy / laryngoscopy or rigid oesophagoscopy).
when is emergency endoscopy needed for forming body?
Any red flag signs
Any sharp or long (>5cm) object in the oesophagus
when is urgent endoscopy ie in 24 hrs needed for forming body?
Oesophageal obstruction (unable to swallow saliva)
Blunt oesophageal FB
Magnets proximal to the duodenum
when is non-urgent endoscopy needed for forming body?
Disc or cylindrical batteries which have passed into stomach without signs of injury
Coins may be observed for up to 24 hours before removal if asymptomatic
what is obstructive sleep apnoea?
intermittent and recurrent apnoeic or hypopnoeic episodes secondary to collapse of the upper airways during sleep
RF for OSA?
obesity
male
smoking
excess alcohol
sedative drugs
children: tonsillar/adenoid enlargement
features of OSA?
excessive daytime sleepiness and reduced concentration
snoring, choking episodes, or observed apnoea
how do you assess OSA?
epworth sleepiness scale
what score on Hepworth indicated disease?
This scale is a score out of 24, with a score >10 indicating abnormal daytime sleepiness. Scores 11-15 suggest mild to moderate impact, whilst scores 16-24 suggest severe disease
ix for OSA?
polysomnography
oxygen saturation monitoring overnight
mx for OSA?
weight loss advice, increased exercise, smoking cessation, and alcohol reduction.
moderate - severe = CPAP
For those with mild OSA or unable to tolerate CPAP, intra-oral devices, such as a mandibular advancement device,
surgical mx for OSA?
uvulopalatopharyngoplasty (UPPP), laser-assisted uvulopalatopharyngoplasty (LAUP), radiofrequency ablation of the tongue base, or suspension of the hyoid bone.
children = tonsillectomy / adenoidectomy
complications of OSA?
inform the DVLA - sleepiness impact work and driving
significant cardiovascular co-morbidity - HTN, IHD and stroke
what is tonsillitis?
inflammation of the palatine tonsils
where are tonsils located?
palatine tonsils are located within the oropharynx as part of Waldeyer’s ring
what is in waldeyer’s ring?
collection of lymphatic tissue located within the pharynx, forming a ringed arrangement, comprised of the pharyngeal tonsils (adenoids), tubal tonsils (x2), palatine tonsils (x2), and lingual tonsil.
what causes tonsillitis?
MOSTLY viral - adenovirus, rhinovirus, influenza, and parainfluenza, or secondary to glandular fever, caused by Epstein-Barr virus (EBV)
bacterial - Streptococcus pyogenes, S. Aureus, and M. Catarrhalis
features of tonsillitis?
odynophagia or dysphagia
pyrexia, halitosis, or a “hot potato voice”
cough or coryzal symptoms may also be present
erythematous and swollen tonsils
purulent exudate
trismus - limited mouth opening
what is the censor criteria?
ix of tonsillitis?
clinical diagnosis
routine bloods (FBC, U&Es, CRPs, LFTs, and clotting)
CT neck scan with intravenous contrast if a deep neck space infection
mx of tonsillitis?
sufficient analgesia
hydration
abx if bacterial
glandular fever - no contact sports 6wks
surgery for tonsillitis?
tonsillectomy
indications for tonsillectomy?
≥7 episodes in the preceding year, or ≥5 episodes in each of preceding 2 years, or ≥3 episodes in each of preceding 3 years
Suspected malignancy or the presence of sleep apnoea
Two previous peritonsillar abscesses
complication of tonsillectomy?
secondary bleeding (>24hrs post-op) from infection to the tonsillar bed
treated medically with antibiotics and hydrogen peroxide mouth wash
complications of tonsillitis?
quinsy - peritonsillar abscess
how does quinsy present?
severe sore throat (worse unilaterally), pyrexia, and severe odynophagia. Associated symptoms include stertor and trismus
extensive erythema and soft palate swelling
deviated uvula
mx of quinsy?
intravenous antibiotics, with regular analgesia and topical analgesic throat sprays
needle aspiration (using topical local anaesthetic) or an incision and drainage (with further opening via use of Tilley’s forceps).
