week 2 ENT trauma Flashcards by J H

how to take Hx of nasal trauma

Mechanism of injury [Fight, sport, fall...]
When
LOC (loss of consciousness )
Epistaxis
Breathing

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how to examine nasal trauma

Bruising
Swelling
Tenderness
Deviation
Epistaxis

Facial tenderness
Infraorbital sensation
CNs(extra-ocular exam)
(look from behind to examine)

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when to involve specialist with nasal trauma case

septal haematoma (rare) - reduced blood supply leading to abscess then get necrosis

profuse epistaxis

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how to diagnose nasal #

clinical diagnosis (investigations superfluous)

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how to treat nasal #

Based on deviation/cosmesis

make sure Breathing is okay

Review in ENT clinic 5-7 days post-injury - can then Manipulate under anaesthetic (MUA) or not intervene

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complications of nasal #

Epistaxis – particularly ant ethmoid

CSF leak can lead to meningitis

Anosmia – cribriform plate fracture

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where are the two common areas for nose bleeds to arise from in the nose?

little’s area (arteries and front)

venous plexus (at back)

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why is epistaxis so common?

Vascular organ secondary to incredible heating/humidification requirements

Vasculature runs just under mucosa (not squamous)

Arterial to venous anastamoses

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what arteries supply the nose

Sphenopalatine A
Ethmoid A
Greater Palatine A

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management of epistaxis

Resuscitate on arrival if necessary

squeeze lower part of nose, sit forwards

Arrest/slow flow: pressure, ice, topical vasoconstrictor +/- LA (Lignocaine + adrenaline, Co-phenylcaine)

Remove clot: suction, nose blowing

Anterior Rhinoscopy

Cautery / pack (rapid rhino packs)

300 rigid nasendoscopy

Cauterise vessel: silver nitrate / diathermy

Bleeding controlled
Arrange admission if packed/poor social circumstances
FBC, G&S
Please don’t consider sedation!!!

Consider arterial ligation (particularly for AEA bleed)

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management of nasal trauma complications (of CSF leak)

CSF leaks – often settle spontaneously – need repair if not within 10 days.

Site of fracture may be cribriform plate

Role of antibiotics not clear – ascending infection

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what ear trauma can occur

Pinna Haematoma

Ear Lacreations

Temporal bone fractures

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what is Pinna Haematoma? why does it occur

cauliflower ear.

due to blood clot or [other collection of fluid] under the perichondrium, lifts it up and less cartilage.

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treatment of Pinna Haematoma

excise and drain, then suture

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why do lacerations of the ear occur?

Blunt trauma

Avulsion

Dog bites

Tissue loss

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management of ear laceration

Debridement, put ear back in right place, suture (wrap in tissue in ice if complete detachment)

Under LA
then give Antibiotics if cartilage exposed

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temporal bone # PC

Injury mechanism
Hearing loss
Facial palsy
Vertigo
CSF leak

Associated injuries (often occurs with many severe injuries = polytrauma EG: assault, RTA…)

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examination of temporal bone #

Bruising – Battle sign (around back of ear), [+racoon eyes]

Condition of Tympanic Membrane and ear canal

CNVII test (facial palsy)

Hearing test

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what are the two types of temporal bone #? which is better?

longitudinal/otic capsule sparing - better

transverse/otic capsule involved - worse

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things associated with transverse temporal bone #

20% of #s
Frontal blows
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 (50%)
Vertigo

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things associated with longitudinal temporal bone #

80% of #
Lateral blows
Fracture line parallels the long axis of the petrous pyramid
Bleeding from external canal due to laceration of skin and ear drum
Haemotympanum (conductive deafness)
Ossicular chain disruption (conductive deafness)
Facial palsy (20%)
CSF otorrhoea

management of temporal bone #

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

what are the types of hearing loss

Conductive
Sensorineural
Mixed
Central

causes of conductive hearing loss

fluid (blood, effusion, CSF),

tympanic membrane perforation (trauma or chronic)

Ossicular problem (trauma, erosion)

Stapes Fixation - Otosclerosis

causes of sensorineural hearing loss

Sensory – cochlea Neural – 8th cranial nerve

what two types of neck trauma are there?

penetrating (knife, gun, MVA, self-harm, industrial/household incidents) blunt (MVA, sports injuries[clothesline tackle])

who does penetrating neck trauma occur in? mortality

young, male, glasgow. 2-6%

what is the worst zone to be affected in penetrating neck trauma ?

zone 1, then 3, then 2

what does zone 1 of neck contain? (lower neck )

``` Trachea Oesophagus Thoracic duct Thyroid Vessels – brachiocephalic, subclavian, common carotid, thyrocervical trunk Spinal cord ```

what does zone 2 of the neck contain (middle neck)

``` Larynx Hypoharynx CN 10,11,12 Vessels – carotids, internal jugular Spinal Cord ```

what does zone 3 of the neck contain (upper neck, = base of skull + jaw )

Pharynx Cranial Nerves Vessels – Carotids, IJV, Vertebral Spinal Cord

Hx of neck trauma

Mechanism of injury Pain - location, nature, intensity, onset, radiation Aerodigestive tract - dyspnoea, hoarseness, dysphonia, dysphagia - haemoptysis CNS problems - paraesthesias, weakness

examination of neck trauma

``` A – airway (stridor, hoarseness) B – breathing (RR, accessory muscles) C – circulation (BP, HR, palpable pulse) D – disability E – full exposure ``` Secondary survey [through platysma?, zone of neck, bleeding/haematoma, Aerodigestive injuries, Neurological – power, sensation upper arm]

what to do initially with PC of penetrating neck trauma

Hx - where possible Exam - ABCDE secondary survey - [through platysma?, zone of neck, bleeding/haematoma, Aerodigestive injuries, Neurological – power, sensation upper arm]

what to look for in secondary survey of the neck after ABCDE of neck trauma is done?

through platysma?, zone of neck, bleeding/haematoma, Aerodigestive injuries, Neurological – power, sensation upper arm

what defines a penetrating neck injury vs a superficial?

through platysma = penetrating.

how to treat superficial neck trauma injury?

wash out and close up

how to investigate neck trauma

FBC, G&S / XM AP/Lateral neck - ?FB CXR – haemo-pneumothorax, emphysema CT Angiogram – vascular, pseudoaneurysm, laryngeal, aerodigestive tract MRA

management of penetrating neck trauma

Urgent exploration – expanding haematoma, hypovolaemic shock, airway obstruction, blood in aerodigestive tract (spitting blood bad) Laryngoscopy, bronchoscopy, pharyngoscopy, and oesophagoscopy Angiography – embolize, occlude surgery if object imbedded MDT approach!!!

what can occur due to facial trauma? what type of injury is needed

orbital #/injury le fort # high energy, disfigurement may be problem

what is the Second commonest midfacial fracture

orbital floor # (AKA blowout)

what causes impact injury to globe?

Large enough object not to penetrate globe Small enough object not to fracture orbital rim

Hx and examination of suspected orbital floor #

Pain Decreased visual acuity Diplopia Hypoaesthesia in infraorbital region ``` Periorbital ecchymosis Oedema Enopthalmos Restriction of ocular movement Bony step of orbital rim ``` Opthalmic examination

investigations of orbital blowout #. what is usually injured in this #

CT Sinuses ‘tear drop’ sign Blow out fracture – medial wall and floor

management of orbital blowout #

Conservative Surgical repair of bony walls if: - Entrapment - Large defect - Significant enophthlamos

what is a Le fort # 1

Horizontal. Passes horizontally above teeth apices

what is a Le fort # 2

Pyramidal. Nasal bridge, through frontal processes of maxilla, through lacrimal bone and inferior orbital floor, then through under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates.

what is a Le fort # 3

Transverse. Craniofacial dysjunctions.

Hx and examination of le fort #

``` Mechanism of injury LOC & confusion Airway Vision Cranial nerves Dental Occlusion ``` ``` 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 ```

how to investigate le fort #

XR – C-spine, Waters view CT = image of choice

management of le fort #

surgery - reduce # and fix | maxillofacial - along vertical and horizontal buttresses

clinically what can occur with le fort 2 #, 3#?

airway obstruction will be literally holding patients mid-face forward (to allow ventilation)