What kind of intubation do we want to avoid? What options do we want to consider? 3
Avoid nasal tracheal intubation (Avoid NG tubes (or any tube in the nose) until the extent of the injury is determined) 1. Endotracheal intubation, 2. laryngeal mask airway, 3. cricothyroidotomy
Shock rarely develops from facial bleeding alone. How should we control this hemorrhage? 2
1. Apply direct pressure 2. May need nasal packing for epistaxis
Physical examination findings that will help reveal 90% of ENT fractures. So this is what we will focus on. 1. Nose? 3 2. Ears? 3 3. Oral and mandibular exam? 4
Nose 1. CSF rhinorrhea 2. Septal hematoma 3. Nasal fracture Ears 1. Subperichondral (Auricular) hematoma 2. Hemotympanum 3. Battle sign Oral and mandibular exam 1. Mandibular deviation, 2. malocclusion of teeth, 3. paresthesia, 4. tongue blade test
What is the picture showing?
What is the significance of this?
1. Direct communication with the CNS exists due to disruption of the bony barrier and tear in the dura
2 Significant risk for CNS infection
How do you distinguish between clear nasal discharge and CSF?
1. Clinical history!
2. Filter paper and look for “halo” or “double ring” signs
3. Test for glucose with glucose oxidase paper
What is this a picture of?
1. Septal hematomas occur from trauma to the what?
2. What kind of injury most occurs in adults to cause this?
4. Treatment? 2
5. What can lead to the formation of bilateral hematomas?
1. anterior nasal septum
-Significant trauma and nasal fracture
-Can occur with simple falls or minor altercations
-Drain and pack
-Antibiotics (Augmentin)…. if abscess suspected IV Clindamycin and admission
5. Cartilage fracture
Complications from not draining a septal hematoma include:
What may a septal abscess lead to?
May spread to: the paranasal and intracranial structures resulting in
1. intracranial abscess,
2. orbital cellulitis,
3. cavernous sinous thrombosis
Whats the most commonly fractured bone in the face?
1. Diagnosis is usually based on what?
2. How will the nose look and feel?
3. What should we look for? 3
4. What kind of inspection is mandatory with a suspected broken nose?
1. Diagnosis usually based on physical exam
2. Nose usually edematous and tender
3. Look for
4. Inspection with a nasal speculum mandatory to rule out septal hematoma
5. Manage (closed reduction) 2-10 days post injury to allow for reduction of swelling
1. Caused by? 2
-Direct trauma to the auricle
-Caused by separation of the cartilage from the perichondrium resulting in avascular necrosis
-Drain within 7 days,
-daily follow up for a few days,
-antibiotics to cover staph
1. What is cauliflower ear?
2. What is the PP behind it?
3. Causes of cauliflower ear? 3
4. What is the key to prevention for this?
1. Failure to drain hematoma
2. Stimulation of cartilage growth
-Laceration through the cartilage
4. Prevention with protective head gear for wrestling, boxing, rugby, and martial arts is key
Management of ear laceration? 4
1. Can do a single layer closure through skin and perichondrium but not the cartilage (might hyperstimulate cartilage and it doesnt have much blood supply)
2. Pressure dressing to prevent hematoma
3. Close follow up
4. Can use posterior auricular block for anesthesia
Findings of Middle Ear Injury
2. Amber or clear middle ear effusion
3. Otorrhea (clear or bloody ear canal drainage)
4. Hearing deficit by Weber and Rinne tuning fork tests
7. Retroauricular hematoma (Battle sign)
8. Facial nerve deficit may be a sign of basilar skull fracture or associated with a middle ear injury
Basilar skull fracture can be secondary to a fracture in which bones?
What is involved in 75% of basilar skull fractures?
3. sphenoid or
4. ethmoid bones
What is hemotympanum indicitive of?
Indicative of basilar skull fracture and middle ear injury
(may not always have the basilar skull fracture with the middle ear injury but often will)
Battle Sign is indicitive of what?
Occurs how soon after injury?
1. Indicative of basilar skull fracture
2. Occurs 6-12 hours after injury
1. What do we want evaluate with this?
2. May have hemorrhagic ottorhea from what?
3. How should we manage penetrating foreign bodies?
4. How should we manage clots?
1. Evaluate for blood and CSF and make sure its from the ear and not just from blood from the head
2. TM rupture or other middle ear injury
3. Leave penetrating foreign bodies there until further evaluation with imaging
4. Leave clots in the external auditory canal if other signs of middle ear injury (ENT physician to evaluate)
Evaluate for further injury (skull fracture)
1. What do we want to evaluate? 5
2. What test is 96% sensitive and 65% specific for mandible fractures?
-Evaluate the bite
-Tooth fractures or
-Look for trauma of the tongue and
2. Tongue blade test 96% sensitive and 65% specific for mandible fracture
1. Management? 3
2. Workup? 4
Blunt Trauma to the Neck
What do we really need to address right away?
Patient may deteriorate rapidly…. Impending airway obstruction
First thing you need to do is determine if the airway and patient are stable or unstable
Mechanism of Injury
1. Blunt injury is most commonly caused by?
2. How does blunt trauma occur?
3. What can prevent this? 2
1. Most commonly from motor vehicle accidents
2. Forward thrust
3.Decrease incidence- seat belt harness and air bags
Initial evaluation of laryngealtracheal trauma
1. ATLS principles
2. Intubation hazardous (if too much trauma you may make things worse)
3. Respiratory distress
---Tracheotomy under local anesthesia
4. Avoid cricothyroidotomies
---Worsen injury (if they have direct trauma)
5. If no acute breathing difficulties
---Detailed history and careful physical examination
Diagnosis of Laryngeal Injury
History questions? 7
Physical Exam? 7
1. Change in voice
7. Inability to tolerate the supine position
1. Respiratory rate
3. Neck skin
--Contusions, Abrasions or Line pattern
4. Subcutaneous emphysema
5. Tracheal deviation
6. Open wound
--Exposed tracheal cartilage
7. Don’t probe open wounds
--May dislodge a hematoma
How should we diagnose an unstable laryngeal injury? 2
Stable? 5 (first best test)
1. Tracheotomy and
2. neck exploration
1. Flexible fiberoptic laryngoscopy in the ER****
2. CT scan,
3. direct laryngoscopy,
Management of Laryngeal Trauma
of laryngealtracheal injuries?
1. Minimum of 24 hours of close observation
2. Head of bed elevation
3. Voice rest
4. Anti-reflux medication
5. Serial flexible fiberoptic exams
6. Antibiotics for laryngeal mucosa disruption
1. Laryngeal trauma uncommon but ___________
2. Initial management should follow what?
3. Tracheotomy should be performed on patients exhibiting what?
4. In patients with no acute breathing difficulties what should we do?
2. ATLS principles
3. respiratory distress….anticipate and call ENT or surgeon
4. a detailed history, careful physical examination and appropriate diagnostic tools should be use to differentiate the need for medical from surgical management
Nasal Foreign Body
1. Symptoms? 4
2. Diagnosis? 2
-Direct visualization (nasal speculum or rhinoscopy) or
Remove with forceps or suction (or get creative)
Describe an example of Classic Case History of nasal foreighm body?
Toddler with unilateral foul smelling nasal discharge
1. What is the most common site for bleeding in the nose?
2. What area bleeds tend to be more severe?
1. Most common site of the bleeding is in the anterior portion (Kiesselbach’s plexus)
2. Posterior bleeds tend to be more severe and harder to treat
Look for underlying cause of epistaxis
2. epistaxis digitorum,
3. foreign bodies,
5. vascular malformation,
6. chronic sinusitis,
9. irritants, etc.
4. liver disease,
6. blood dyscrasias
Initial Management of bloody noses?
1. Have patient blow nose to clear clots
2. Spray with a topical vasoconstrictor like Afrin (oxymetazoline)
3. Lean forward and pinch the nares together for at least 20 minutes continuously
4. Examine the nose with a nasal speculum to locate the site of bleeding
Big deal because treatment differs
Difficult to tell but most bleeds are anterior.
What is mandatory for nose bleeds?
Visual inspection of the nares is mandatory
What do we cauterize the bleed with?
silver nitrate sticks
(field needs to be fairly dry for this to work)
1. If cautery is unsuccessful or not practical what should we do?
2. Leave in place for how long?
3. Follow up is required when?
4. Follow up is required when?
5. What may occur if packing is too tight?
1. place packing or nasal tampon
2. Several methods
3. Leave in place for about 48 hours
4. Follow up is required in 24-48 hours
5. Necrosis may occur if packing is too tight
How should we manage a posterior nose bleed?
1. Call an ENT to do this
2. Most of these patients are admitted to the hospital
1. Severe bleeding…..shock (Are they on Warfarin?)
3. otitis media
4. Pressure necrosis from packing
5. Toxic shock syndrome
1. Most common etiology is what?
3. Diabetics at high risk?
4. Difficult to treat why?
5. How do we distinguish it from seronegative arthritis?
1. Most common etiology S. Aureus and pseudomonas
3. Diabetics at high risk
4. Difficult to treat due to poor blood supply
5. inflammatory causes related to seronegative arthritis at times indistinguishable from infection usually the ear lobe is spared
1. Etiologies? 3
2. Treatment? 4
3. Blast injuries
2. Keep ear dry
3. Recheck in 4 weeks to determine if TM is healed
4. Audiometry evaluation
1. When is TM rupture in need of immediate referral? 2
2. Most common cause?
3. Treatment? 3
1. If associated with vertigo or facial nerve deficit,
2. Infection is the most common cause
-Keep ear dry until TM is healed (Most heal spontaneously)
-Recheck in 4 weeks for healing
*Ofloxicin for 3-4 days, oral abx may be indicated as well
*Gentamicin, neomycin sulfate, tobramycin contraindicated (ototoxic)
1. Presentation? 5
2. Evaluation? 2
3. Treatment? 3
4. Etiology? 2
Don’t mess with them, diagnosis can be clinical,
-Lateral neck xray may help support your suspicion…..
-think ahead, call ENT or surgeon and prepare to intubate
-Emergent ENT referral
-Haemophilus influenzae type B,
Peritonsillar abscess (AKA Quincy)
1. A complication of what?
2. How is this dangerous?
3. Airway occlusion may be more pronounced in who?
1. Complication of tonsillitis
2. Can extend into deep neck structures and occlude the airway
3. in children due to the smaller airway size
Peritonsillar Abscess (AKA Quincy)
1. Severe unilateral throat pain,
3. difficulty swallowing,
4. “hot potato” voice,
6. neck pain,
7. ear pain on affected side,
Management of Peritonsillar Abscess
1. Supportive therapy
2. Work up (Diagnosis is mainly clinical)
3. Immediate ENT referral for I&D
4. IV antibiotics
What may you want to do in the workup of a peritonsilar abcess?
1. +/- lateral neck Xray to rule out other causes
2. +/- CT scan with contrast
Management of Peritonsillar Abscess
Supportive Therapy includes?
Retropharyngeal space extends from where to where?
the base of the skull to the tracheal bifurcation
1. In what area?
2. Serious and can be life threatening how? 2
1. Deep tissue neck infection
2. Serious and can be life threatening
-Spread of infection
Etiology in children? 1
Etiology in adults? 3
1. Usually from a lymph node that drains the head and neck
1. Penetrating trauma (chicken bones, etc)
2. From an infection in the mouth/teeth
3. Lymph nodes that drain the head and neck
Retropharyngeal abscess signs and symptoms
3. Neck pain
4. Limitation of cervical motion
5. Cervical lymphadenopathy
6. Sore throat
7. Poor oral intake
8. Muffled voice
9. Respiratory distress
10. Stridor more likely in children
11. Inflammatory torticollis
Work up: Retropharyngeal Abscess
2 (gold standard?)
1. Lateral soft tissue Xray of the neck during inspiration
2. CT scan of the neck is the gold standard
Treatment Retropharyngeal Abscess
1. Immediate ENT consult
2. Treatment is surgical incision and drainage (surgical drainage)
3. IV hydration and IV antibiotics to be started in the emergency room
4. Clindamycin adult dose 600-900 mg IV q 8 h
5. ampicillin-sulbactam (Unasyn) adult dose 1500-3000 mg q 6 h
Retropharyngeal Abscess: complications
1. Extension of the infection into the mediastinum (Pleural or pericardial effusion)
2. Upper airway asphyxia
3. Sudden rupture
What would a sudden rupture of a retroharyngeal abscess cause?
1. Aspiration pneumonia
2. Widespread infection….sepsis
1. What is ludwig's angina?
2. Describe the type of infection/severity of infection?
1. Infection of the submandibular space
-Floor of the mouth under the tongue
2. Rapidly progressive gangrenous cellulitis of the soft tissues of the neck and floor of the mouth
1. Ludwigs Angina: Swelling of the soft tissues and elevation and posterior displacement of the tongue causes what?
1. airway obstruction
2. Etiology: odontogenic 90% of cases (staph, strep and bacteroides)
Signs and symptoms of Ludwigs angina
1. Dental pain,
2. recent history of dental procedures,
3. neck swelling/neck pain,
4 change in voice,
5. difficulty swallowing,
6. tongue swelling,
Life threatening emergency!!!!!!!!!!
PE findings on Ludwigs angina?
1. Bilateral submandibular swelling
2. Protruding tongue
Diagnosis (1) and treatment (3) of ludwigs angina?
1. Clinical diagnosis
-CT to determine the degree of abscess
-Incision and drainage
-Broad spectrum antibiotics
Ex: combo of penicillin, clindamycin and metronidazole
Foreign Body Aspiration
1. Most common in what age group?
2. Smaller objects are what?
3. Larger objects are what?
4. If objects get into the laryngopharynx?
1. Most common less then 5 years old
2. Smaller objects aspirated
3. Larger objects swallowed
4. Laryngeal objects
5. Airway emergency
When should the following be removed in a foreign body situation:
Same day of diagnosis
1. What is Pott’s Puffy Tumor
2. Is a complication of what?
3. Most commonly seen in who?
4. Can lead to what? 2
6. Treatment? 3
1. Osteomyelitis of the frontal bone
2. Complication of frontal sinusitis or trauma
3. Most commonly in kids and teens
4. Can lead to
-intracranial abscess or
-venous sinus thrombosis
5. Work up: CT
6. Immediate referral for
7th Nerve Palsy (Bell’s Palsy)
1. Etiology? 3 (most common)
5. What do we have to rule out?
-Most cases are idiopathic
-Consider Lyme Disease in endemic areas
-HSV or Herpes zoster may be the cause
2. Hallmark is sudden onset
3. 80% recover to normal or near normal function
4. Steroids +/- acyclovir
5. Rule out tumor
How do you differentiate Bell’s Palsy from Stroke?
In Bell's palsy they can't raise their eye brow and in stroke they can
1. Involves what structure?
2. Common bugs? 2
4. Treatment? 2
1. Involves the deeper dermis and subcutaneous fat
2. Most common Strep and Staph
3. Can progress rapidly
4. Treat with antibiotics
1. Involves what parts of the face? 2
2. Describe the lesions?
3. Associated with what symptoms?
1. Involves the
2. erysipelas lesions are raised above the level of surrounding skin
3. Usually associated with systemic symptoms
4. IV antibiotics for Strep and Staph
1. Rarely, infections involving the medial third of the face (ie, the areas around the eyes and nose) can be complicated by what?
2. Why is this serious?
1. septic cavernous thrombosis,
2. since the veins in this region are valveless.