Intra-temporal Failure of Rx = \> ENT referral TM retraction w/ hearing loss TM rupture Ossicular erosions Retraction poscke formation Chronic supporative otitis media Cholesteatoma Mastoiditis Extra-temporal Meningitis Epidural abscess Brain abscess CSVT SD empyema Carotid artery thrombosis

Stone in salivary gland, \> 80%submandibular gland See DDx Salivary gland swelling Viral: Mumps Bacterial : Staphylococcus, Streptococcus viridans, S. pneumoniae, and H. influenzae OA Clinical exam with palpation Ix CT / USS - size and location of stone Mx MMassage/heat Sialagogues (ex lemon candies to promote salivation) Antibiotics if infection suspected (fever, increasing pain, purulent d/c) Lithotripsy as per ENT Treatment failure may end with surgical removal of entire gland ENT F/U important immediately if stone cannot be removed in ED, or within 4-5 days if it can be.

ENT Flashcards by Sonal Shah

Zones - Neck

Zone 1 - clavicle to cricoid cartilage
Zone 2 - cricoid cartilage to angle of mandible
Zone 3 - angle of the mandible to base of skull.

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Neck Trauma Signs

Hard signs assoc 90% major injury
Hard signs straight to OT - only delay to secure airway
Soft signs CT angiogram neck
No significant signs observation

Vascular hard signs
Active bleeding, Large expanding haematoma, , bruit/thrill, reduced GCS, shock, focal neuro deficit
Vascular soft signs - Minor bleeding, small haematoma

Aerodigestive hard signs
Aphonia (severe), Respiratory distress, Stridor, Haemoptysis, Haematemesis, Air/bubbles in wound
Aerodigestive soft signs - dysphagia, dysphonia, SC air

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Epiglottitis

Orgs

Hib > Strep, Staph

PSeudomonas/Candida - immunocomp

Toxic / Stridor / Resp distress / Posturing

DDx

Croup

Bacterial tracheitis

Diphtheria

Per-tonsillar abscess / Retropharygeal abscess

CXR

Thumbprint sign

Calm

Nebulised adrenaline

IV ABx - ceftriaxone

IV dexamethasone

ETT

ICU/Anaesthetics/ENT

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Epistaxis - blood supply

Anterior + Posterior ethmoid artery

Superior labial artery

Greater Palatine Artery

Sphenopalatine artery

POSTERIOR

Sphenopalatine Artery

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Malignant Otitis Externa

Necrotising otitis externa

HIGH MORTALITY

Continguous spread to cartilage, periosteum, soft tissues, bone

Orgs

Pseudomonas

MRSA

Fungal - immunocomp

Consider in those Rx for Otitis Externa for 2-3 weeks + otaligia + ottorhoea

Toxic

Cranial nerve

Intracranial extension

CT/MRI

IV cipro 400mg TDS

ENT admit

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Tinnitus

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Sudden Hearing Loss

< 3 days, > 30dB

Poor prognosis = Severe Hearing loss + vertigo

70% Idiopathic

13% Infectious

Others - otologic Dx, trauma, vascular, haem, neoplastic

Ear exam

Weber + Rinne test

ENT referral

Poor evidence for other modalities

Steroids PO
Steroids Intratympanic
Hyperbaric oxygen
Antiviral therapy
Vasoactive / Hemodilution therapies/dextran/Mg

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Conductive Hearing Loss

Cerumen

Serous OM

Otitis Externa

Neoplastic

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Acute Suppurative Otitis Media

Mixed bacterial / viral infection of middle ear
Orgs: Strep penumoniae > Hib > Moraxella catarrhalis

Presentation
Signs/Sx of middle ear inflammation +
Bulging TM, Erythema, otalgia, fever
Middle ear effusion
TM opacity, dec TM mobility, Air-fluid level, ottorhoea

Immediate Abx for:
Systemic features
TM rupture
Indiginous
Difficult follow up
Age
- < 6mo
- 6-24 mo if no improvement in 24 hrs
Only hearing ear or cochlear implant

Mx
* Kids < 2yrs = Treat 10d
* Kids > 2yrs = treat if unwell or in 48hrs x5d
* Adults = treat x10d
Kids with tubes = ciproHC BD x7d
ABx choice
* Amoxycillin 30mg/kg BD
* Aug if Rx failure 22.5mg/kg BD

Complications:
Meningitis
Mastoiditis
Intracranial abscess
Lateral sinus thrombosis
Facial nerve paralysis
Middle ear effusion
Chronic OM - glue ear

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Bullous Myringitis

Infection => blistering of TM

Orgs Associated

S. pneumoniae

M. attarhalis

H. influenzae

M. pmeumonia

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Complications AOM

Intra-temporal

Failure of Rx = > ENT referral
TM retraction w/ hearing loss
TM rupture
Ossicular erosions
Retraction poscke formation
Chronic supporative otitis media
Cholesteatoma
Mastoiditis

Extra-temporal

Meningitis
Epidural abscess
Brain abscess
CSVT
SD empyema
Carotid artery thrombosis

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Post-tonsillectomy bleeding

Primary w/in 24 hrs post-op

Secondary > 24hrs

MOVIE
Immediate large bore IVC x2
Hb, X match, G+S
IVF 10mls/kg if shocked
TXA bolus
Transfusions reqiured in 10-12% of secondary bleeds.
Early Referral to ENT help early
Topical adrenaline on gauze pressure on bleeding point, if tolerated by the patient
Silver nitrate cautery may be attempted.
Antibiotics if infection suspected (ENT use it regardless).
Steroids

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Salivary Gland Swelling

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Sialolithiasis

Stone in salivary gland, > 80%submandibular gland

See DDx Salivary gland swelling

Viral: Mumps

Bacterial : Staphylococcus, Streptococcus viridans, S. pneumoniae, and H. influenzae

Clinical exam with palpation

CT / USS - size and location of stone

MMassage/heat
Sialagogues (ex lemon candies to promote salivation)
Antibiotics if infection suspected (fever, increasing pain, purulent d/c)
Lithotripsy as per ENT
Treatment failure may end with surgical removal of entire gland
ENT F/U important immediately if stone cannot be removed in ED, or within 4-5 days if it can be.

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DDx neck Masses

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Cholesteatoma

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Keratinised desquamated epithelial collection in middle ear or mastoid process (AbN collection of skin within middle ear cleft)

Painless hearing loss

Foul smelling D/C - scant

Pearly mass evident behind TM

Refer to ENT OPD unless acute complication

Complications:

Intra-temporal

Loss of hearing
Infection

Extra=temporal

CN VII palsy
Meningitis
Temporal lobe abscess
CVST
Vertigo/Nystagmus

Ramsay Hunt Syndrome

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Herpes Zoster Oticus

Ipsilateral CN VII palsy + otalgia + vesicles auditory canal

CN VIII - hearing and balance impairment

Analgesia

Antivirals : valaciclovir 1g TDS / acyclovir 800mg 5x daily

Mastoiditis

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Epistaxis Mx

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Direct pressure
Silver nitrate (bad with active bleeders)
Cautery (don’t use longer than 10-15 seconds can perforate) start peripheral to central
Bilateral septal cautery not advised
Can use gelfoam or surgical
Rapid Rhino or epistats (leave in for 48-72hrs)
? ABx reduce risk of TSS

POSTERIOR

Large bleed despite adequate anterior packing
Rapid Rhino or Foley
REMEBER NEED TO APPLY TRACTION
Pack both nares with foley, inflate balloon w/ sterile water, tug until well seated, apply traction (use green umbilical clamps)
Leave packs in for 2-5days as per ENT
ABx important (Keflex or Amox-Clav)
Refractory cases may need CT and IR

Epistaxis Causes

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IDIOPATHIC

LOCAL

Trauma - injury or FB or Picking
Traumatic internal carotid artery aneurysm
Infection - URTI, nasal mucormycosis, neonatal
Environment - Low humidity, irritants
Allergies
Drugs - cocaine
Lesions - polyps

SYSTEMIC

Coagulopathy - DOACs, blood dyscrasias, DIC
Hepatic Disease
DM
EtOH abuse
Renal diseas - chronic nephritis
Drugs - chemo, drug induced thrombocytopaenia
Metabolic - vit K / folic acid deficiency

Drug Induced Tinnitus

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Deep Neck Spaces

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Deep Neck Space infections

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PERI-TONSILLAR

RETROPHARYNGEAL - ENT Emergency

space extends from base of skull to superior mediastinum
usually < 6years old

PARAPHARYNGEAL

odontogenic or pharyngotonsillar infection or contiguous spread from other deep space neck infections
Polymicrobial

MASTICATOR

submandiubular / sublingual

OTHER FEATURES:

Polymicrobial - Rx TAZ / cex + met / clindamycin
Comp:

> Airway obstruction

> Continguous spread → Mediastinitis, mediastinal or myocardial abscess

> Abscess rupture, aspiration pneumonia + empyema

> Lemierre’s syndrome - septic thrombosis if IJV

pharyngitis followed by severe sepsis
Dispo: ICU +/- OT for I+D

Lemierre’s Syndrome

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Septic thrombophlebitis of IJV + bacteraemia

Pharyngitis followed by severe sepsis

EPI

mostly affects children, adolescents and young adults
delayed diagnosis is common

MICRO

fusobacterium species, especially fusobacterium necrophorum most commonly (an anaerobic GNB, a part of normal oral flora)
⅓ polymicrobial bacteraemia (anaerobic strep + gm -ve anaerobes)
other gram positive causes have been reported (e.g. S.aureus)

PATHOPHYSIOLOGY

Primary infection is followed by local invasion of the lateral pharyngeal space then septic thrombophlebitis of the IJ vein

primary source of infection is commonly the palatine tonsils and peritonsillar tissue
Metastatic infections following the IJ thrombophlebitis occur in >2/3 of cases
lungs, joints, liver, muscle, pericardium, brain and skin

COMPLICATIONS

Thrombosis may propagate from the IJ vein inferiorly into the subclavian vein or superiorly into the cavernous, sigmoid or transverse sinuses
metastatic infection
DIC (~5%)
meningitis (3%)
septic shock
death (near 100% mortality in the pre-antibiotic era)

CLINICAL FEATURES

Clinical manifestations vary according to the presence of metastatic complications

Fever (but may appear otherwise well)
Pharyngitis/peritonsillar abscess
Anterior cervical lymphadenopathy
Neck mass/tenderness (~50%)
Trismus
Cranial nerve 10, 11, 12 palsies
Septic arthritis (most commonly hip or knee)
Jaundice/hepatomegaly
Shock

INVESTIGATIONS

Septic screen
Joint fluid aspirates if appropriate

Imaging

CXR — metastatic infection of the lungs is common: nodules, cavities, effusions
CT Neck with contrast — IJV thrombophlebitis and/or neck mass/ collections

MANAGEMENT

Resuscitation

address life threats such as airway compromise, respiratory failure and septic shock

Specific therapy

Supportive care and monitoring
antibiotics
- if severely unwell: piperacillin+tazobactam 4/0.5 g (child: 100+12.5 mg/kg up to 4/0.5 g) IV q8h
- if systemically unwell: benzylpenicillin 1.2 g (child: 50 mg/kg up to 1.2 g) IV q6h AND metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV q12h
- if systemically well: amoxicillin/ clavulanate or clindamycin
- typically 2-6 weeks duration
anticoagulation
- controversial (administered in about 1/4 to 1/3 of case reports)
- some recommend if IJ thrombophlebitis leads to venous sinus thrombosis or failure to improve with antibiotics

Penetrating Neck Trauma - Nerve Injuries

1. Subclavian vein/artery injury → Phrenic n → hemidiaphragm paralysis 2. Common Carotid or IJV → Vagal n → tachycardia 3. Thyroid+/- tracheo-oesophageal injury → Recurrent laryngeal n. 4. Sympathetic chain → Horner's syndrome

Perichondral Haematoma

Need to drain to prevent permanent cartilage destruction leading tocauliflower ear deformity CI Haematomas > 7 days Recurrent haematoma Referral to ENT 1. Large overlying skin avulsion 2. Severe crush injury 3. Devitalised tissue 4. Complete or near complete avulsions / amputations 5. Large cartilage defects > 5mm 6. Involvement of auditory canal

ENT Flashcards

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