4. Emergencies in Ear Nose and Throat Flashcards
(126 cards)
1
Q
Name common emergencies affecting the ear?
A
- Foreign Body
- Haematoma
- Traumatic TM Perforation
- Temporal Bone Fractures
- Hearing Loss
- Mastoiditis
2
Q
What are the signs and symptoms of foreign bodies in the external auditory canal?
A
– Otalgia
– Otorrhea
3
Q
What might be the complications of a foreign body in the EAC?
A
Secondary complications:
– Infection, mucosal erosion, TM perforation
4
Q
Describe the management of a foreign body in the EAC
A
Kill any live insects
Remove foreign body with micro alligator forceps
Irrigation ( do not use if organic FB )
Antibiotics
5
Q
When is irrigation for removal of FB from the EAC contraindicated?
A
If the FB is organic
6
Q
For what type of object should a crocodile forceps not be used?
A
Smooth round objects
7
Q
What implement would be suitable for removing a round, smooth FB from the EAC?
A
Blunt Hook
8
Q
What instrument is suited for removing the vast majority of FB’s found in the EAC?
A
Suction
9
Q
What is the cause of Auricular Haematoma?
A
Trauma, shearing forces.
10
Q
What is the clinical appearance of auricular haematoma?
A
Fluctuant bluish swelling of auricle
11
Q
What are the potential complications of auricular haematoma?
A
Complications: – Infection – Abscess – Cartilaginous necrosis – Deformity (Cauliflower Ear)
12
Q
What is the Tx for auricular haematoma?
A
Management
– Drainage (Needle aspiration/Recent, Incision & Drainage/Delayed presentation 2-3days)
– ABX
– Compression Dressing
13
Q
What type of mechanisms may leaf to Traumatic TM perforation?
A
Foreign bodies (eg., cotton buds, hairclips, matchsticks). Explosion. Slap on the ear. Fractured skull. Welding sparks. Barotrauma. Syringing (Instrumentation) Water sports.
14
Q
What are the signs and symptoms of Traumatic TM perforation?
A
– Hx of Trauma – Tympanic Membrane perforation, possibly with ragged edges – Bloody Otorrhea – Otalgia – Hearing Loss – Tennitus
15
Q
Describe how you would evaluate a Traumatic TM Perforation?
A
- History.
- Careful examination of the ear, especially to exclude infection (Otoscopy). Removal of blood clot should not be performed.
- If the perforation is clearly seen, its size and shape should be documented.
- Test Hearing. Audiogram if possible – if not possible Tuning Fork Test and clinical assessment of hearing.
- If the patient has had head injury, it is important to record the function of the facial nerve and to note if any CSF leakage is present.
- Simple vestibular assessment if indicated.
16
Q
Describe broadly, the management of Traumatic TM perforation?
A
- Reassurance: explain to the patient that there is a good chance of spontaneous resolution (unless due to a welding spark).
- If the perforation is contaminated, consider either giving an oral antibiotic or an antibiotic + antibiotic drops or drops alone.
- Keep water out of the ears until the perforation has healed.
- Review within 6 weeks but if the ear discharges, the patient should be advised to see their general practitioner.
- Consider surgery if the perforation persists for longer than two months.
17
Q
What is Otitic Barotrauma?
A
Trauma, as a result of an inability to ventilate the middle ear which causes insufficient equilibrium in th middle ear. (Diving, Flight)
18
Q
Describe the management of barotrauma?
A
Management:
– Repeated Valsalva maneuver
– Topical nasal decongestants
– Myringotomy & PE tube
19
Q
What are the signs and symptoms of a temporal bone fracture?
A
Hx – Blunt force trauma
– Battle’s sign – Raccoon eyes – Haemotympanum – Hearing loss – Dizziness – CSF / Bloody otorrhea – CN VII palsy
20
Q
What causes longitudinal temporal bone fractures?
A
The line of force runs roughly from lateral to medial
21
Q
What are the potential consequence of a longitudinal temporal bone fracture?
A
Conductive Hearing loss (Ossicular chain disruption)
VII Nerve Palsy (Extend through the facial nerve canal)
22
Q
What causes Transverse Temporal Bone Fractures?
A
Trauma to the occiput or cranial-cervical junction
Line of force running roughly anterior to posterior
23
Q
What are the potential complications of a transverse temporal bone fracture?
A
Fracture passing through the vestibulocochlear apparatus = Sensorineural hearing loss, Equilibrium disorders
VII Nerve Palsy – Path often close to the nerve’s labyrinthine segment
24
Q
What investigations should be performed for a transverse temporal bone fracture?
A
Investigations:
– Otoscopy
– CT temporal bone
– Audiogram
25
What is sudden hearing loss defined as?
SNHL ≥ 30 dB over 3 contiguous frequencies within 3 days or less
26
What are the potential aetiologies of sudden hearing loss?
1. Viral
2. Trauma (Mechanical,Acoustic)
3. Autoimmune (RA, Sarcoidoses, SLE)
4. Neurological
27
What should be asked as part of the history follow sudden hearing loss?
Otological.
Past medical history.
Drug history.
Systemic illnesses.
28
What examinations should be performed following sudden hearing loss?
General.
Otological.
Neurological.
29
What investigations should be performed for sudden hearing loss?
Audiogram – day of presentation if possible.
Otoscopy
Haematological (FBC, ESR Glucose Syphilis Serology Rheumtoid factor. ANCA)
30
Describe the management of Sudden Hearing Loss?
– Ear protection / Avoidance
– Corticosteroids, Antiviral, Vasodilators, Diuretics, Anticoagulants
Tx: If in “Steroid Responsive Zone” on audiogram, steroids dexamethasone 4 mg bd for 7 days as an outpatient, except if contra-indicated.
If not in the “Steroid Responsive Zone”, on audiogram, observe.
31
Pinna pushed down and forward?
Subperiosteal Abcess
32
What is the Tx for subperiosteal abcess
– Intravenous ABX
– I&D (If/Req)
– Mastoidectomy (If Req)
33
What are the 5 emergencies involving the nose, studied?
1. Foreign body
2. Nasal bone fractures
3. Septal Haematoma
4. Epistaxis
5. Sinusitis
34
What are the signs and symptoms of foreign body in the nose?
Purulent (foul smelling) UNILATERAL nasal discharge (Rhinorrhoea).
Nasal Obstruction
Vestibulitis affecting one nostril is almost always a sign of a foreign body.
Organic material presents early with purulent discharge; inorganic bodies may remain inert for ages.
35
What are the potential complications of foreign bodies in the nose?
Orbital or intracranial infection may develop if undetected.
| Button batteries fit easily into a child’s nose and rapidly cause severe burns with subsequent septal perforation.
36
How would you assess a foreign body in the nose before management?
Anterior Rhinoscopy – a good light and suction are required because secretions may obscure the foreign body.
Radiographs are of limited value since most objects are radiolucent.
The other nostril must be examined to exclude a second foreign body.
37
Describe the management of a foreign body in the nose?
Atraumatic removal in a controlled manner if the child is co-operative. Anaesthesia may be required if this is not successful.
Rigid nasal endoscopes are useful to visualise the object and facilitate atraumatic extraction.
If the patient is a child attempts at removal may cause distress. (Blanket for limbs. Hold head steady)
Good visualization: headlamp & nasal speculum
Alligator forceps should be used to remove cloth, cotton, or paper
Other hard FB are more easily grasped using bayonet forceps or Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin hook, or right angle ear hook
38
How might you remove a fb in the nose of a child?
If the patient is a child attempts at removal may cause distress. An adult may need to restrain a young child by wrapping the child in a blanket in order to restrain its limbs and the child’s head is held steady. This may be necessary as unsuccessful attempts may push the object back further with an increased risk of inhalation or traumatic haemorrhage. In some instances a general anaesthetic may be required.
39
What are the potential complications of the Tx for removing fb from the nose?
Attempted removal of foreign bodies by untrained personnel may result in epistaxis, displacement of the foreign body and/or ingestion or inhalation.
40
What are the signs and symptoms of nasal fracture?
– Deformity of nose
| – Swelling, ecchymosis, epistaxis
41
What is the Tx for a nasal fracture?
– Local Anesthetic or General Anesthetic
| – Closed or Open reduction
42
What are the common causes of septal haematoma/abcess?
Trauma
| Surgery
43
What are the signs and symptoms of a septal haematoma/abscess?
Soft, fluctuant swelling of the Septum
44
Describe the management of septal haematoma/abscess
– Needle aspiration or Incise & Drain
– Bilateral nasal packing for several days
– Prophylactic antibiotics
45
What are the two types of epistaxis?
Local/Systemic (aka General in the guide)
46
What are the main local causes of epistaxis?
Trauma, Nose picking, blow injury, surgery
Drying Mucosal Dessication
Nasal Septum Perforation
Inflammatory (allergy, seasonal rhinitis, perennial rhinitis, atrophic rhinitis)
Infective (Acute Viral, Bacterial, Fungal=Assoc w/aids)
Topical Medications (Steroids)
Foreign Bodies
Tumours/Polyps
47
What are the main systemic causes of epistaxis?
Congenital. (Haemophilia, Christmas Disease, Von Willabrand’s disease, Haemorrhagic Telangiectasis.
Acquired blood disorders. (Leukaemia, Aplastic, Anaemia, Lymphoma, Thrombocytopenia.)
Acquired Diseases (Liver, Renal Disease)
Vitamin
Granulomatosis (Sarcoid/Wegeners).
Endocrine - Pregnancy.
Hypertension.
48
Which areas are most frequently associated with epistaxis?
Most anterior epistaxis originates at Kiesselbach’s plexus (or Little’s area).
Most posterior bleeding originates at Woodruff’s plexus, behind the middle turbinate at which the sphenopalatine artery enters the nose.
49
Describe the steps involved in the assessment of epistaxis patient?
Obtain a full history from the patient - check for predisposing factors.
Assess blood pressure and pulse rate and signs of clinical shock.
Ascertain if possible the approximate amount of blood loss.
Patient should be sitting upright and leaning forward to lower blood pressure. Pinch the nostrils tightly together.
Rule out the use of medications eg. non-steroidal anti-inflammatories or anti-coagulants which may be predisposing to the bleed.
Carry out a physical examination to rule out obvious signs of telangiectasia.
General ecchymosis or bruising indicating systemic causes predisposing to the haemorrhage.
Venous access.
Full blood count and haematocrit should be carried out, check coagulation screen, liver function and renal profile.
50
Describe the initial objectives in the management of epistaxis?
Nose bleeds can be life-threatening. So objective is to secure ABCDE.
Depending on the acuity may need resuscitate as needed,
eg if BP low or dizzy on sitting up.
ABCs; IVI, SAO2, etc. Monitor vital signs often.
Obtain History
51
What should be asked in an epistaxis history?
```
Which side?
Trauma?
How much loss?
On warfarin/aspirin?
Note past medical history. (congenital/acquired condts)
```
52
What should be the initial conservative management in the stable patient with epistaxis?
1. Ask him to apply pressure by pinching the lower part of nose for 15min while mouth-breathing and sitting forward so blood can be spat into a bowl.
2. Fully decongest(eg with ephedrine0.5% drops).
3. Place ice pack on the dorsum of the nose (ice may also be sucked).
RESULTS: Controlled with pressure (follow up= observation or with local mucosal therapy (cotton bud w/co-phenylcaine))
OR Profuse and not controlled with pressure (see next steps)
53
Describe the management of a profuse epistaxis that is uncontrolled by pressure?
If bleeding is profuse and uncontrolled by pressure:
1. Prepare silver nitrate cautery.
2. Encourage the patient to blow out nasal clots.
3. Look in side (headlamp+speculum) and remove clots (gentle suction; spray on lidocaine and phenylephrine (vasoconstrictor); wait a few minutes.
4. Find bleeding points (eg indicated by prominent surface clot, often on the anterior septum. Apply cautery for ~10sec.
5. If you cannot see the bleeding point, or simple measures fail to control bleeding then the nose will have to be packed.
54
What precautions should be taken when cauterising bleeding points?
Start from the edge of the bleeding point and move in on a radius.
Remember: “silver nitrate cauterizes everything it touches.” Keep it away from alae nasae.
Get support to keep your hand steady.
Never cauterize both sides of the septum as this risks rupture.
55
What types of nasal packs are available? How is the amount of packing required determined?
```
Nasal Tampon (expands w/moisture)
Inch ribbon gauze coated with vaseline (48hrs) or paraffin paste (3 weeks) (traditional method)
```
The packing should begin at the site of the bleeding and gradually layered along the floor of the nose until control is achieved.
Very often patients requiring packing require admission with significant morbidity
Bilateral packing may result in sleep apnoea, esp in elderly and those on resp depressents, monitor on ward and have IV access.
If Packing Fails --> Catheters
56
Describe how catheters are used to control nasal haemorrhage?
They utilise proprietary double balloon catheters which may be inserted into the nasal cavity with ease.
One of the balloons is placed in the nasal cavity adjacent to the site of the bleeding, the other balloon is inflated in the naso-pharynx to prevent the blood being swallowed.
The balloons are inflated to 5 to 8 cc’s of air and can be left in position for 48 hours and deflated to assess if the haemorrhage has been controlled.
The advantage of using these catheters is that they are easy to insert and discomfort can be relieved by simply deflating the catheter.
57
What is term given to epistaxis which cannot be controlled by packing, catheterisation or other non-active means?
Refractory Epistaxis
58
What active intervations may be used to treat refractory epistaxis?
Insertion of a post nasal pack (rolled gauze in nasopharynx placed using foley caths by ENT's - careful observation)
Embolization – Femoral artery entry, catheter to external carotid artery. Success 80-87%. Radio-neurologist. Not always available.
Arterial Ligation – Of Ethmoidal arteries via medial orbit
59
Which arteries supply the nasal septum?
Internal Carotid Artery (Anterior ethmoidal artery. - Posterior-ethmoidal artery. - Greater palatine.)
External Carotid (- Sphenopalatine artery. - Superior Labial artery.)
60
What is sinusitis?
Inflammation of the nasal and paranasal sinus mucosa
61
Name the two categories of sinusitis?
```
Acute Rhinosinusitis
Chronic Rhinosinusitis (>3months)
```
62
What factors predispose to sinusitis?
Allergy - seasonal / perennial.
Structural - septal deviation – abnormality of the osteomeatal complex.
Pathological - nasal polyps, hyptertrophic turbinates, tumour (benign or malignant).
Perennial non-allergic rhinitis or vasomotor rhinitis.
Mucociliary clearance abnormality (primary (ciliary or mucous) or secondary-infection/smoking).
Immunodeficiency (local / systemic) – IgA / IgG deficiency, panhypogammaglobulinaemia
Medications - Aspirin, ACE inhibitors, OCP, Beta-blockers, rebound hyperaemia of nasal mucosa following chronic vasoconstrictor use. Eg. ephedrine, otrivine. Iatrogenic ie. post-surgery (secondary atrophic rhinitis)
Idiopathic.
Hormonal = pregnancy, OCP (oestrogen), = older men (testosterone).
63
What are some of the complications of sinusitis?
Purulent rhinorrhea, fever, frontal/retro-orbital headache
Personality change, lethargy, seizures, focal neurological deficits
Cavernous sinus thrombosis, meningitis, extradural abscess, intracranial abscess & subdural empyema
64
On what, do the clinical symptoms of acute rhinosinusitis depend?
Depends on which sinus is primarily involved.
65
What symptoms are common to all forms of sinustitis, regardless of sinus affected?
1. Infective Nasal and Post Nasal Discharge
2. Nasal block.
3. Cacosmia.
4. General malaise
5. Pain (Location varies)
66
What are the signs and symptoms of Maxillary Sinusitis?
EXAMINATION (SIGNS)
Pyrexia.
Tenderness over cheek and teeth. mucopus in nose (from middle meatus).
SYMPTOMS
Maxillary/dental pain.
Infective nasal and post nasal discharge.
Nasal block cacosmia.
General malaise.
Oedema of the upper eyelid may be present. (swelling rare, consider dental, tumour or complication of sinusitis)
67
What are the signs and symptoms of Frontal Sinusitis?
```
EXAMINATION
Pyrexia.
Tenderness over forehead.
Mucopus in nose (from middle meatus). Swab for C&S.
Periorbital cellulitis.
```
```
SYMPTOMS
Supraorbital pain.
Infective nasal and post nasal discharge.
Nasal block.
Cacosmia.
General malaise.
```
68
What are the signs and symptoms of Ethmoid Sinusitis?
```
EXAMINATION
Pyrexia
Tenderness / Erythema of the medial canthus of the eye, swab for C&S.
Mucopus in nose (from middle meatus).
Periorbital cellulitis.
```
```
SYMPTOMS
Pain over medial canthus.
Infective nasal and postnasal discharge.
Nasal block.
Cacosmia.
General malaise.
```
69
What are the signs and symptoms of Sphenoid Sinusitis?
EXAMINATION
Pyrexia.
Mucopus in nose (above middle turbinate).
Nasal endoscopy (rigid or flexible endoscope – LA).
FBC
Nasal swab.
Plain X-Rays of sinuses (occipito-frontal, occipito-mental, lateral)
CT Scan (coronal and axial – bony windows).
SYMPTOMS
Severe headache over vertex or retro-orbital area.
Infective nasal and postnasal discharge.
Cacosmia.
70
What is the treatment for acute sinusitis?
Medical.
1. Appropriate antibiotic x 10 days eg. amoxicillin, augmentin or vibramycin.
2. Decongestant nose drops / spray x 1/2 weeks eg. ephedrine, otrivine or steroids. Analgesia.
3. Bed rest.
(Consider admission to hospital for IV antibiotics, topical decongestants, CT scan if unresponsive to above measures or in presence of complications.)
Surgical (only if unresponsive to medical treatment or in presence of complications).
1. Antral washout (maxillary sinusitis).
2. Frontal trephine (frontal sinusitis).
3. Functional endoscopic sinus surgery (FESS) or external fronto-ethmoidectomy (extensive fronto-ethmoid maxillary sinusitis.
71
What are the potential complications of acute rhinosinusitis?
Bacteraemia. Septicaemia.
Chronic Rhinosinusitis?
```
RESPIRATORY TRACT
Adenotonsillitis.
Pharyngitis.
Laryngitis.
Tracheitis.
Bronchitis.
Lower Respiratory Tract Infection.
```
EAR
ASOM
Glue Ear (OME).
Eustachian Tube Dysfunction.
ORBIT
Periorbital cellulitis/abscess – infection anterior to orbital septum.
Orbital cellulitis/abscess – infection posterior to orbital septum. Suspect if visual acuity (especially colour vision), diplopia (opthalmoplegia), proptosis (exophthalmos), lateral displacement of eye, chemosis (conjunctival oedema).
Optic neuritis.
72
What is the Tx for the orbital complications of acute rhinosinusitis?
IV antiobiotics / decongestants x 24 hours.
Urgent CT Scan.
Surgical drainage if extension into the orbit.
73
What is the Tx for intracranial complications of acute rhinosinusitis?
IV antitiotics/ decongestants x 24 hours.
Treatment of specific neurosurgical complication.
Surgical treatment of sinusitis.
74
What factors predispose to the development of chronic rhinosinusitis?
Nasal Allergy.
Dental Infection.
Gross Septal Deformity.
75
What is the correlation between nasal polyps and chronic sinusitis?
65% of patients with nasal polyps have chronic sinusitis.
76
What are the symptoms of chronic rhinosinusitis?
Nasal Block.
Chronic rhinorrhoea (anterior & posterior – intermittently infective).
Hyposmia.
Anosmia.
Facial pain.
Itch and sneezing (if underlying allergy).
Cachosmia may occur in infections of dental origin
77
What signs of chronic rhinosinusitis may be present on examination?
Mucopus in the nose of nasopharynx.
Pyrexia is usually present.
Tenderness over the antrum and on percussion of the upper teeth (swelling is most commonly of dental origin).
Nasal endoscopy (rigid or flexible endoscope – LA).
CT Scan (coronal and axial – bony windows).
78
What might be a useful test to perform in the setting of chronic rhinosinusitis?
Allergy testing if history is suggestive – skin prick test, RAST (allergen specific IgE.
79
What is the Tx for chronic rhinosinusitis?
Antibiotics – eradicate infection.
Long term topical steroids – 3-6 months – systemic side effects occur only if higher than recommended doses are used.
Bed rest.
Restore mucociliary clearance – aeration and drainage with topical steroids.
Surgery eg. functional endoscopic sinus surgery (FESS).
Intranasal ethmoidectomy.
External frontoethmoidectomy.
Retain maximum normal anatomy as possible if surgery is performed.
Identify and treat any underlying cause.
80
Name some treatable causes of chronic rhinosinusitis?
o Correct septal deviation.
o Nasal polypectomy.
o Treat underlying allergy.
o Immunoglobulin therapy for immunodeficiency. o Pregnancy – avoid treatment if possible.
o Rhinitis medicamentosa: steroids, consider surgery.
81
What are the possible complications of Rhinosinusitis Surgery?
Nasal.
(Epistaxis, Infections, Mucosal adhesions)
Orbital. (Haematoma [periorbtial / orbital] Optic nerve damage.Abscess / cellulitis (periorbital / orbital).
Intracranial. (CSF Leak, Meningitis, abscess, Anosmia.)
82
What are the 5 emergencies involving the throat, studied?
```
Quinsy
Epiglottitis
Ludwig's Angina
Foreign Body Ingestion
Upper Airway Obstruction
```
83
What is a peritonsillar abscess also known as?
A Quinsy.
84
What might a peritonsillar abscess form?
As a result of acute tonsillitis
85
In whom is quinsy common and in whom is it rare?
Common in Adults
| EXTEMELY Rare in Children!
86
What are the symptoms of a peritonsillar abscess?
Severe dysphagia with referred otalgia.
High temperature.
Swelling of the tonsillar lymph node.
Malaise.
87
What are the signs of a peritonsillar abscess?
Similar to those of acute tonsillitis with medial displacement of the tonsil to the midline.
Trismus (spasm of the pharyngeal muscles)
Buccal mucosa is dirty and foetor is present.
The anatomy of the buccopharyngeal isthmus is distorted by the quinsy.
88
How would you assess a patient with a peritonsillar abscess
– FBC, ESR (erythrocyte sed rate), C-RP
| – Throat Swab
89
What is the Tx for peritonsillar abscess?
Antibiotics – high dose of intravenous antibiotic followed by a five day course of oral antibiotics.
Draining the abscess – may not always be necessary.
Usually a tonsillectomy is carried out about six weeks after this procedure if there is a history of recurrent tonsillitis or this is the 2nd episode of quinsy.
90
Describe the indications for drainage of peritonsillar abscess and describe how it would be performed
If trismus is present and pus suspected then drainage is required.
A small incision is made midway between the base of the uvula and the site of the upper wisdom tooth. (Avoiding the internal carotid artery)
The blades of a sinus forceps are then inserted into the abscess cavity and opened. If the patient is a child drainage should be carried out under anaesthetic.
Can do needle aspiration in the same location
91
What are the indications for tonsillectomy in quinsey?
Hx Recurrent Tonsillitis
| 2nd Episode of Quinsy
92
What are the possible complications of a quinsy?
Vascular fibrous tissue found lateral to the tonsil after a quinsy makes tonsillectomy difficult.
Bleeding from a quinsy is an important and serious sign of complication due to erosion by the peritonsillar pus of the internal carotid artery.
93
What is considered a more appropriate name for epiglottitis?
Supraglottitis?
94
What is epiglottitis?
Acute severe swelling of the supraglottic mucosa
95
What is the causative agent in epiglottitis?
Group B Haemophilus Influenza or Group A Strep
96
In whom is epiglottitis common?
Mainly in the age group 3 to 7 though adults may also be affected.
97
What are the signs and symptoms of epiglottitis?
Sudden onset severe pyrexia (fever)
Severe sore throat and dysphagia
Drooling
Stridor
Breathing with raised chin and open mouth
The child tends to sit in the trip position (sitting erect with hands for support)
98
How would a child with epiglottitis tend to sit?
The child tends to sit in the trip position ie. sitting erect with hands behind for support.
99
How is a diagnosis of epiglottitis made?
Diagnosis is based on the sudden onset, the toxicity, the presence of drooling and the patient in the characteristic position.
Basically severity of symptoms out of keeping with the signs seen on exam
100
What might be present on examination of the oral cavity during epiglottis?
Inflammation (maybe) but not enough to account for severity of sign and symptoms.
101
What should and should not happen immediately in suspected epiglottitis?
Should: transfer to hospital immediately and take to operating theatre at slightest hint of dx.
Should Not: Send for X-Ray or Lie flat for bloods.
(Airway can totally obstruct during either)
NO TONGUE DEPRESSORS
NO MUSCLE RELAXENT
102
What is the definitive Tx for epiglottitis?
Surgery under general anesthetic (inhalation only)
NO MUSCLE RELAXENT
Once under, secure airway with rigid bronchoscope or ET tube or in emergency by performing tracheostomy.
Once airway secured, bloods taken for culture.
IV 3rd Gen Cephlasporins
Siblings placed on prophylactic antibiotics.
Extubation usually possible after 48 hours
103
What signs might be visible on X-ray in epiglottitis?
Thumb shaped epiglottis on lateral neck xr
104
What is Ludwig's Angina?
Rapid swelling cellulitis of the sublingual & submaxillary spaces
105
What are potential causes of Ludwig's Angina?
Dental infection.
Infection floor of mouth
Infection of salivary gland
106
What are common causative agents of Ludwig's Angina?
Streptococci, Bacteroides, Staph .Aerues
107
What are the signs and symptoms of Ludwig's Angina?
```
Tongue → upward & backward
Edema & erythema of neck under chin & floor of mouth.
Open mouth
Airway obstruction
Fever
```
108
Describe the management of Ludwig's Angina?
– Tracheostomy (if req)
– IV antibiotic
– I&D
– Tooth extraction
109
What are the symptoms of foreign body ingestion?
Dysphagia.
Drooling
Stridor.
Chest pain and regurgitation or vomiting occur with impacted oesophageal foreign bodies..
110
What complication can occur with chronic foreign body obstruction in the oesophagus?
Secondary oedema can occur with chronic foreign bodies and may compromise the tracheal airway.
111
Where do coins commonly lodge in the oesophagus?
Coins often become lodged at the postcricoid area or cricopharyngeal region.
112
Which patients may be prone to foreign body obstruction and what precautions should be observed for these patient?
Some patients with carcinoma of the oesophagus may present with an oesophageal foreign body and adequate visualisation of the oesophageal mucosa is mandatory at the time of therapeutic endoscopy
113
How is a foreign body obstruction of the oesophagus diagnosed?
Plain radiographs
| Posteroanterior (PA) and lateral chest views are mandatory
114
Why is a Barium Swallow contraindicated to dx foreign body in Oesophagus?
Barium swallow is not recommended in a patient with complete oesophageal obstruction as aspiration may ensue.
115
What is the Tx for foreign body in the oesophagus?
Removal using a rigid endoscope under general anaesthesia.
116
Name 3 specific interventions that are contraindicated in FB obstruction of oesophagus and say why?
The use of papain (enzymatic tenderizer) should be avoided as an impacted sharp bony object may cause further ulceration and/or oesophageal perforation.
Fogarty Balloon Catheters are not recommended – deaths have occurred previously from attempted extractions using this method.
Flexible endoscope should be avoided as irregular edges may tear the oesophageal mucosa. This can be avoided by drawing the object into the lumen of a rigid endoscope.
117
What complication s may result if the foreign body is a button battery?
Small, disc shaped batteries contain KOH or NaOH are capable of causing caustic burns with possible oesophageal perforation and should be removed as an emergency.
118
What are the possible complications of foreign body in the oesophagus?
Oesophageal perforation (Monitor + chest x-ray prior to discharge)
Severe chest pain radiating to the back suggest oesophageal perforation.
Pneumothorax and pneumomediastinum indicates penetration of the oesophageal wall has occurred and the patient is at risk of developing potentially fatal mediastinitis.
119
What are the symptoms of a foreign body in the airway?
Children – may be subtle – intermittent wheezing/cough
Hoarseness
Dyspnoea
Previous Hx of choking or gagging (esp infant) = investigated throughly.
120
How might the characteristics of a stridor be used to localise a foreign body in the airway?
Inspiratory Stridor = Supraglottic/Glottic Region
| Expiratory+Inspiratory Stridor = Tracheal/Subglottic impactation
121
What are the signs associated with organic fb obstruction of the airway?
Vegetative foreign bodies tend to swell with secretions and cause bronchial obstruction and/or respiratory distress.
122
How is a FB in the airway diagnosed?
```
Radiograph H+N on insp+exp. Not always diagnostic.
Mediastinal Shift (FB as ball valve=hyperinflation = away from FB, or FB complete occulsion = collapse/atelectasis = Toward FB)
```
123
What is the Tx for a FB in the airway?
Co-op Anesthetic + ENT.
Tracheobronchial FB = Rigid bronchoscopy + ventilating endoscope. (atraumatic removal under direct vision while side port ventilates = goal).
Specialised forceps may need to be used.
Observation for ≥24 hours
124
What are the potential complications of FB in the airway/Tx?
Minor complications include atelectasis and wheezing.
Airway obstruction, laryngeal oedema, bleeding and post-operative laryngospasm are potential problems that may be encountered following bronchoscopy.
Persistent pneumonia is common after removal of long-standing objects.
Bronchial stenosis, pneumothorax, fistula formation and lung abscess are other rare potential sequelae.
125
What are the signs and symptoms of Upper Airway Obstruction?
```
Stridor = Incomplete Upper Airway
Aphonia = Complete Upper Airway
```
Wheeze = Incomplete lower airway
Loss of Breath Sounds = Complete lower airway
126
What is the emergency Tx for upper airway obstruction?
Tracheostomy ( also in bilateral vocal cord paralysis).
