Emergency in Ent

7/28/2019 Emergency in Ent

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1. EAR

FOREIGN BODY

TEMPORAL BONE FRACTURE

2. NOSE

EPISTAXIS

SEPTAL HEMATOMA

3. THROAT

AIRWAY OBSTRUCTION


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Insects Cotton, paper, organic material (seeds)

Small batteries Toys Beads, stones


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Clinical manifestation:

Purulent discharge Pain

Bleeding Hearing loss or sense of fullness Discomfort & agitation Significant discomfort and complain of nausea

or vomiting if a live insect is in the ear canal. Secondary complications: infection & mucosal

erosion


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Workup: No specific laboratory or

radiologic studies

Pysical examination is themain diagnostic tool

the object seen on direct

visualization or otoscopicexamination.


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Management Insect should be killed prior to removal, using

mineral oil or lidocaine (2%). EMLA cream

also effective.

Irrigation, suction is the method of foreignbody removal provided the tympanic

membrane is not perforated Consult an ENT specialist if the object cannot

be removed or if tympanic membrane

perforation is suspected.


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If infection or abrasion is occur, fill the earcanal 5 times/day for 5-7 days with acombination antibiotic and steroid oticsuspension (eg, Cortisporin or Cipro HC).


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The temporal bone is the most complex bone in the

human body.

It houses many vital structures, including the

cochlear and vestibular end organs, the facial nerve,

the carotid artery, and the jugular vein. Motor vehicle accidents are the cause of 31% of

temporal bone fractures.


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Hearing loss: conductive or sensorineural Dizziness

Facial weakness or paralysis (7% overall) Otorrhea Rhinorrhea More rare: facial numbness and diplopia


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Hemotympanum

Battles sign:postauricular

ecchymosis Raccoon sign:

periorbital ecchymosis
http://images.google.com/imgres?imgurl=http://me.hawkelibrary.com/albums/hemotympanum/26_L.jpg&imgrefurl=http://me.hawkelibrary.com/hemotympanum/26_L&h=2366&w=2403&sz=817&tbnid=AFxH9iBWP8QJ:&tbnh=147&tbnw=150&hl=en&start=3&prev=/images%3Fq%3Dhemotympanum%26svnum%3D10%26hl%3Den%26lr%3D


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Ulrichs Classification (1926)

Longitudinal fractures

Transverse fractures


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The commonest type accounting 80% of all thetemporal bone fractures.

Caused by lateral blows like temporal or parietal

type. The fracture line parallels the long axis of the

petrous pyramid. It starts from the squamousportion of the temporal bone, extends throughthe postero superior portion of the externalauditory canal, continues across the roof of themiddle ear space, anterior to labyrinth to endanteromedially in the middle cranial fossa closeto foramen lacerum and ovale.


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1. Bleeding from external canal due to lacerationof skin and ear drum

2. Haemotympanum (conductive deafness)

3. Fractures involving the bony portion of externalcanal4. Ossicular chain disruption causing conductive

deafness.5. Facial palsy (rare) 20% usually at the level of

horizontal segment distal to geniculate ganglion6. CSF otorrhoea (usually temporary)7. Sensorineural hearing loss can occur due to

consussion


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Comprises about 20% of all temporal bonefractures.

Usually caused by frontal or parietal blow,rarely by occipital blow.

The fracture lines runs at right angle to thelong axis of the petrous pyramid. Usually it

starts in the middle cranial fossa close toforamen lacerum, it crosses the petrouspyramid transeversely to end at the foramenmagnum.


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1. Sensorineural hearing loss due to damage to8th cranial nerve

2. Facial palsy due to damage of facial nerve3. Vertigo4. Labyrinthitis ossificans (this should be borne

in mind before performing cochlear implantin these patient)


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FEATURE LONGITUDINAL TRANSVERSE

Incidence Approximately 80% Approximately 20%

Mechanism Temporal or parietal trauma Frontal or occipital trauma

CSF otorrhea Common Occasional

Tympanic membrane

perforation

Common Rare

Facial nerve damage 20% (most often temporary

and frequently delayed in

onset)

50% (severe, usually

permanent, and immediate in

onset)

Hearing loss Common (conductive type

and possibly high tone

neurosensorial)

Common (severe

sensorineural or mixed)

Hemotympanum Common (associated with

otorrhagia)

Possible (not associated with

otorrhagia)

Nystagmus Common (spontaneous, less

intense)

Common (spontaneous,

intense)

Otorrhagia Common Rare

Vertigo Common (less intense) Common (intense)


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HRCT (high resolution CT) Useful in assessing injuries complicated with CSF leak,

facial palsy or suspected vascular injury.

Usually 1 mm cuts in both axial and coronal planesmust be performed.

Bone window cuts would be really useful

Also indicated when surgical intervention for otologic

complications following temporal bone fracturebecomes necessary

Indicated in patients with persistent cranial nerveinjuries following skull base fracture.


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CT angiography Indicated in evaluation of petrous carotid

artery

MRI Helps in identification of intralabyrinthine

haemorrhage, brain stem injury and nervecompression


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Facial nerve palsy Damaged to chocleo vestibular apparatus causing

sensorineural hearing loss Conductive hearing loss due to ossicular disruption Balance disruption Tinnitus/vertigo CSF leak Perilymph fistula Post traumatic endolymphatics hydrops Cholesteatoma Meningocele/encephalocele Otogenic meningitis Injuries to cranial nerves VI, IX, XI Vascular injuries eg: internal carotid artery and

sigmoid sinus


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Meningocele/encephalocele

Can manifest as a late onset CSF otorrhea,

unilateral clear middle ear effusion, or recurrentmeningitis.

The delay can range from 1-20 years.

Cholesteatoma

Could be due to traumatic implantation of

epithelial elements during injury into the middle

ear cavity.


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Management;ABC, AMPLE HISTORY.PRIMARY SURVEY

HEAD AND NECK EXAMCRANIAL NERVES
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Medical treatment: Stabilize the pt condition Patient with delayed facial paralysis is managed

conservatively with 10-14 days of systemic corticosteroidsunless medically contraindicated.

Surgical treatment

Ossiculoplasty, cochlear implant, facial and decompression,control of CSF leak,


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Epistaxis = bleeding from the nasal cavity

Is a sign, not a disease!


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Nasal septum

Internal carotid:

ant. ethmoidal a. post. ethmoidal a.

External carotid:

splenopalatine a.

greater palatine a.

superior labial a.


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Littles area: = Kiesselbachs plexus Anterior inferior part of nasal septum

Anastomose of:

anterior ethmoidal a. Septal branch of superior labial a.

Septal branch of splenopalatine a.

Greater palatine a.

Woodruffs area Posterior end of inferior turbinate

Anastomoses of: Splenopalatine a.

Posterior pharyngeal a.


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AnteriorKesselbachs Plexus

Posterior

Woodruffs Plexus


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Local cause General cause

Trauma CVS

Infection Disorder of blood and blood vessel

Foreign body Liver disease

Atmospheric changes Kidney disease

Deviated septum Drugs

Juvenile angiofibroma Acute general infection


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Initial first-aid Assessment of blood loss

Evaluation of cause history taking Procedure to stop bleeding


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First aid Bleeding @ littles area: pinch nose with thumb and index

finger for 5 minutes Trotters method:

patient sit

lean forward over a basin to spit any blood Breathe quietly from mouth

Cold compress reflex vasoconstriction @nose bridge Suck ice and put at the palate

Cauterisation Useful in ant. epistaxis Anaestherise the area first cauterise using silver nitrate or cogulate with

electrocautery


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Anterior nasal packing bleeding profuse or hard to localise the site

Use ribbon gauze soaked with paraffin

Gauze: 1 meter long, 2.5 cm (12mm in child) width

Remove pack in 24 hour or 2-3 days

give systemic antibiotic


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Posterior nasal packing Posterior bleeding into

the throat

Postnasal pack =Belloque tamponade

three silk tied to a piece of

gauze cone shape

Must be hospitalised

Alternative:

Foleys catheter

Nasal balloons


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Collection of blood b/wcartilage septum & muco-perichondrium

Most often associated withfracture

Dx: grape-like, blue bulgethat obstructs nares

Left untreated: can causesaddle nose deformity


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Treatment

Prompt aspiration /drainage to prevent

saddle nose

Packing / splinting

Prophylactic anitbiotics

Tetanus prn


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Neonatal : Congenital tumors, cysts, webs: Laryngomalacia: Subglottic stenosis

Children : Laryngotracheobronchitis: Epiglotittis: Foreign body: Retropharyngeal abscess: Respiratory papilloma

Adults : Laryngeal cancer: Laryngeal trauma: Epiglottis & deep neck infection


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The epiglottis is a cartilaginous

structure covered with mucous

membrane Epiglottitis is an acute

inflammation of the epiglottisand pharyngeal structures

Can be severe life threateningdisease


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Age 3-7 yrs old H. influenzae type B,

Group A Streptococcus Triad of drooling,

dysphagia, and distress. High fever Positioning- tripod

position

Dyspnea/ Inspiratorystridor/ accessory muscleuse / muffled voice

Brassy cough


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CBC: leukocytosis

Film lateral neck

thumb shapedepiglottis

Avoid tongue

depressor

Controlled intubation Intravenous ATB


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Secure airway with endotracheal intubation. Mightneed cricothyroidotomy.

Child should sit upright

Humidified oxygen Hospitalization No tongue blades IV antibiotics:Ceftriaxone (Rocephin) cefotaxime

(Ceftin), Ampicillin with chloramphenicol


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Evaluate for extubation 24-48 hours postintubation.

24-48 hours post extubation Rifampin prophylaxis for 4days for household

contacts if: children in household have notbeen vaccinated with the entire series


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Emergencytracheostomy in thecase of upper airwaysobstruction

1. Tumor in the larynx2. Trauma of the larynx3. Bilateral vocal cord

paralysis

4. F.B. in the larynx afterfailure of Heimlichsmanuver

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Emergency in Ent