- You are the ED intern on duty. You are asked to see and treat a 20 year-old man who has broken his nose playing football three hours previously. It has not stopped bleeding. You can ignore all other issues other than those related directly or indirectly to do with his nose.
How will you proceed to assess and treat his nosebleed?
Primary first aid is a priority in a patient who presents with epistaxis and this includes the ABCs of resuscitation .
Assess the pt for haemodynamic stability, including pulse and respiratory rate, and look for signs of shock, such as sweating and pallor.
If the patient is actively bleeding, sit them upright. Lean the patient forward to minimise swallowing of blood and apply digital pressure at the cartilaginous part of the nose for a minimum of 10 minutes.
Consider inserting a large-bore intravenous cannula if bleeding is severe and, if appropriate, take a blood sample (for full blood evaluation and blood group determination) and hold.
If the bleeding has not resolved then the nose should be examined with a nasal speculum, topical local anaesthetic, appropriate lighting and PPE.
Cauterisation is first line treatment of an anterior bleed. This can be done using silver nitrate or electrocautery.
Care must be taken during bilateral cautery to prevent septal perforation and treatment should only be administered to a small area surrounding the bleeding point.
if cauterisation is unsuccessful in controlling the bleed, or if no bleeding point is seen on examination, anterior or posterior nasal packs are available. The Rapid Rhino has an inflatable balloon coated in a compound that acts as a platelet aggregator and is the simplest and most effective for anterior bleeds.
If bleeding continues despite anterior nasal packing then a balloon catheter (e.g. Foley Catheter) is inserted into the nose into the posterior pharynx, inflated and retracted to sit in the nasopharyngeal space (this prevented bleeding into the airway) the anterior nose should then be packed.
If bleeding has not resolved then ENT referral is appropriate for surgical management. This can be done via arterial ligation or embolisation.
EXTRA
• 90% of bleeds arise anteriorly from Little’s area (Kiesselbach’s plexus)
o Kiesselbach’s plexus:
Anterior ethmoidal artery (septal branch)
Sphenopalatine artery (lateral nasal branch)
Superior labial artery (septal branch)
Greater palatine artery (septal branch)
• 10% of bleeds arise posteriorly from Woodruff’s plexus:
o Usually the lateral wall but rarely the nasal septum
o Woodruff’s plexus:
Sphenopalatine artery
Posterior nasal artery
Ascending pharyngeal artery
Aetiology:
• Local Causes:
o Trauma
Nose picking (most common)
Fractures to the nasal septum, middle 1/3 of the face, or base of skull
o Foreign body in the nose
o Dry Nose (Rhinitis sicca)
o Vascular Malformations (e.g. nasal haemangioma, HHT)
o Nasal septal defects
o Infections
o Tumours of the nasopharynx
o Medications/ drugs (topical corticosteroids, cocaine)
• Systemic Causes:
o Bleeding disorders (e.g. Anticoagulation/ antiplatelets, VWD, severe thrombocytopaenia, haemophilia)
o HTN
- You are a GP. You are consulted by a 55 year-old man who has a hoarse voice.
What features of his history must you establish before deciding on your next steps?
Hoarseness is an alteration in the voice usually due to a laryngeal disorder.
In the history of this pt it is important to establish:
- the onset and duration
- potential triggering factors (vocal abuse, URTI, allergens, meds)
- other head and neck symptoms (dysphagia odynophagia, otalgia, throat pain, bleeding, post-nasal drip)
- respiratory symptoms
- hypo or hyperthyroid symptoms
- history of smoking and alcohol
- GORD or sinus disease
- past surgeries
- neurological disease history
Red flags to look out for include: - history of smoking - dysphagia - odynophagia (pain on swallowing) - otalgia (ear pain) - stridor - haemoptysis AND recent fevers, night sweats and unexplained weight loss
- You are the ED intern on duty. Your patient is a 30 year-old man who has had a sore throat for three days, which is getting worse. He has difficulty opening his mouth, ear pain on the right and cannot swallow his saliva. On examination he has a temperature of 39°C, pulse 115 bpm.
Oral examination reveals a unilateral, left sided tonsillar swelling with a diffuse, oedematous bulge superior and lateral to the tonsil. The uvula is deviated to the right.
- What is the diagnosis?
- What is the cause of the problem?
- The most likely diagnosis is tonsilitis complicated by a peritonsillar abscess (Quinsy).
Quinsy triad =
- trismus (lockjaw)
- uvular deviation
- dysphonia
Explanation of symptoms:
• Sore throat and difficulty swallowing from the acute infection
• Difficulty opening his mouth (trismus) due to involvement of the motor branch of CN V leading for spasm of the muscles of mastication
• Ipsilateral ear pain due to referred pain
• The uvula is deviated to the contralateral side due to palsy of CN X on the right side
- Several bacteria can cause quinsy, but the most common types are haemophilus influenzae and streptococcus bacteria, particularly streptococcus pyogenes.. The abscess forms , after a bout of severe, untreated tonsillitis, or tonsillitis that is not fully treated.
Another cause is if the Weber glands malfunction and cannot clear the build-up of debris from the area around the tonsils, the tubes that drain the glands may become swollen. This can cause an infection to develop, which gets worse and causes an abscess to form.
- You are the ED intern on duty. Your patient is a 30 year-old man who has had a sore throat for three days, which is getting worse. He has difficulty opening his mouth, ear pain on the right and cannot swallow his saliva. On examination he has a temperature of 39°C, pulse 115 bpm.
Oral examination reveals a unilateral, left sided tonsillar swelling with a diffuse, oedematous bulge superior and lateral to the tonsil. The uvula is deviated to the right.
What is the diagnosis?
What is the management?
- Tonsillitis complicated by a peritonsillar abscess (Quinsy)
- Airway management, drainage, antimicrobial therapy, and supportive care are the cornerstones of management for peritonsillar abscess.
It is important to conduct a primary survey when the pt first comes in and make sure there is no airway compromise. Anxious, ill-appearing patients with drooling and posturing must be monitored continuously in a setting where emergent artificial airway can be established if necessary.
ENT referral is required for surgical intervention. The abscess can be surgically managed through needle aspiration, incision and drainage, or tonsillectomy.
Empirical antibiotic therapy is essential and therapeutic guidelines recommend benzathine penicillin IV and phenoxymethyl penicillin oral.
Supportive care includes provision of adequate hydration, analgesia and monitoring for complications.
- You are on duty in A & E. Your next patient is a 3 year-old child with rapidly progressive airway obstruction, looking toxic, drooling, tachycardic and tachypnoeic, sitting up leaning forward looking worried. The child is not immunised.
- What is the most important differential diagnosis?
- What will you do?
- The most important differential diagnosis is epiglott-itis.
This occurs when bacteria invades tissue of the epiglottis and/ or surrounding supraglottic structures causing inflammation and oedema that causes narrowing and obstruction of the airway.
(CAUSES:
Traditionally Haemophilus Influenzae type b (Hib) – uncommon now due to immunisation
Most cases now involve: Strep pyogenes, Strep pneumoniae, Staph aureus, non-typable H influenzae)
Clinical Features: • Most common in the 1 – 4 year age group but can occur at any age • Acute on set of high fevers (>39C) • Toxic appearance • Sore throat • Tripod position • Drooling • Dysphagia • Muffled voice • Respiratory distress and stridor • Restlessness and/ or anxiety
- FOR MANAGEMENT I WOULD:
• Have the parent stay with the child and assist to prevent anxiety and further obstruction of the airway
• Call for urgent review by paediatrician, ENT, anaesthetic +/- ICU teams
• The first priority is management of the airway by experienced and appropriately trained staff. This can include intubation and oxygenation.
•Once the airway is secured:
o Empirical IV Abx - ceftriaxone
o IV fluids if required
o Analgesia
- Lana is a 52 year-old female who is day one post total thyroidectomy. You are the RMO in-charge of the ward and have been called by the NUM to assess Lana urgently. Lana is having difficulty breathing and her neck looks significantly swollen.
- What is the most likely diagnosis?
- What will you do?
- The most likely diagnosis is a haematoma compressing the trachea. This is a rare but potentially fatal complication of thyroid surgery and generally presents 12-24hrs post-op with neck swelling or pain and signs of airway obstruction.
(Due to major vessel bleeding from ruptured clot or failure of a suture.
May involve superior thyroid or inferior thyroid or associated veins )
- Review the pt immediately and call for help- MET call, anaesthetics/ ICU, surgical registrar
-Call senior + transfer to OT
-Resuscitation (ABCDE):
o A –
If non-critical perform in OT, if critical perform at bedside
Remove superficial and deep sutures and evacuate haematoma
Keep pressure on wound without occluding trachea or carotids.
Attempt intubation
If all else fails, then cricothyroidotomy
o B –
Immediate high flow O2
o C –
Establish IV access
Control haemorrhage
IN THE OT
o The wound is reopened and inspected for location of bleed and haemostasis established
o Drain is placed to remove fluid collecting in bed of haematoma
Pt is then transferred to ICU for observation
- Heather is a 4 year-old girl who had a tonsillectomy seven days ago. She presents to the ED with bleeding per orally. She has bled around two cupfuls of fresh blood in 30 minutes.
You are one of the Emergency Department doctors. Heather is in the waiting room. - What is the diagnosis?
- What is your management plan?”
- The diagnosis is a secondary post-tonsillectomy hemorrhage. It is bleeding that occurs 24 hours or longer after surgery (2-5% pts).
Usually occur 5-10 days post-operatively and are caused by premature separation of the eschar (this may occur due to underlying infection or dehydration). - Heather should be admitted and moved into the resuscitation bay
- primary survey should be conducted and pt should be resuscitated appropriately.
o Airway – position patient forward, encourage spitting blood into bowl, suction as required
o Breathing – O2, OBS
o Circulation – IV access, bloods (FBC, coagulation studies, Group and Hold), IV fluids
- Contact the ENT team early
- If she is stable then inspect the oropharynx and if it is a mild bleed give hydrogen peroxide for pt to gargle (to try and seal) and apply pressure to the tonsillar fossa with gauze soaked in adrenaline or xylocaine spray.
If the bleed is severe then pt should proceed to OT for surgical management such as electrocautery.
- A 45 year-old male comes to your GP practice with a two month history of hoarse voice. He has recently developed a swelling on the left side of his neck. He is a heavy smoker and consumes substantial alcohol daily. You are the doctor examining him.
- What is the most likely diagnosis and examination findings?
- What are relevant investigations/referrals for him?
- The most likely diagnosis is laryngeal cancer (90-95% are SCC carcinoma).
The pt presents with hoarseness and has significant risk factors (like the heavy smoking and etoh consumption). The new swelling on the left side of his neck could be due to cervical lymphadenopathy.
Most likely head and neck examination findings can include:
o Change in voice
o Cervical lymphadenopathy
o Signs of airway obstruction – diminished breath sounds, stridor
o Weight loss or cachexia
o Parotid or thyroid masses
- Relevant investigations and referrals include:
- Referral to an ENT surgeon
FOR
-Urgent laryngoscopy
to visualise the laryngeal inlet for lesions or masses
and assess vocal cord mobility
- Imaging
o CT contrast neck and chest to assess local invasion, LN involvement, presence of metastases or secondary tumours - FNA of neck mass or cervical LN under USS guidance
- whole body PET scan for mets
- A 45 year-old female comes to your GP practice with a one year history of a midline neck swelling. She also gets tremors and says that her heart races at times and has lost some weight that she is pleased about.
What are the relevant investigations that are related to this case?
Relevant investigations include: Pathology: -Thyroid function tests (TFTs). Looking for: o Decreased TSH o Increased free T4, free T3 - Thyroid autoantibodies (positive) o Thyroid peroxidase (TPO) antibody o TSH-receptor antibody - Other: o FBC (normochromic normocytic anaemia, mild leukopenia) o LFTs (elevated ALT and AST) o Hypercalcemia
Imaging:
- Radionuclide thyroid scan (Technetium-99m)
o Normal or elevated uptake
Homogenous: graves
Heterogenous: toxic multinodular goitre
o Decreased uptake: thyroiditis, exogenous thyroid hormone
- Thyroid U/S +/- FNA
o Indicated if suspicious nodules (i.e. macrocalcification, irregular border, increased vascularity)
- ECG (document any arrhythmias or other changes)
- You are working in emergency and you see a 4 year-old boy with fever, left otalgia and acute left facial nerve palsy.
What is the likely diagnosis and what would you do from here?
The most likely diagnosis is acute otitis media.
Clinical features include:
- bulging of the tympanic membrane
- signs of acute inflammation (e.g. marked erythema on tympanic membrane, fever and ear pain)
- middle ear effusion
- irritability, sleep disturbance and decreased appetite.
Management would include:
- Admitting the pt
- adequate and regular analgesia
- Amoxycillin IV as he has systemic systems and facial nerve palsy.
- keep NBM
- urgent referral to ENT
EXTRA- PATHOGENESIS
• Under normal conditions the mucociliary action and ventilatory function of the Eustachian tube clear nasopharyngeal flora that enter the middle ear
• URT viruses can infect the nasal passages, Eustachian tube, and middle ear causing inflammation and impairing these processes
• A middle ear effusion develops and is contaminated with nasopharyngeal bacteria – producing a suppurative inflammatory response
• The pressure against the tympanic membrane leads to pain and the infection leads to fever
• This inflammatory process may also include mastoid air cells
• Pathogens:
o Bacteria: Strep pneumoniae, H. influenzae, Moraxella catarrhalis, Staph aureus, Strep pyogenes
o Virus: RCV, picornaviruses (rhinovirus, enterovirus etc.), coronaviruses, influenza, adenovirus, metapneumovirus
- You are working in emergency and you see a 4 year-old boy with fever, left otalgia and acute left facial nerve palsy.
- What is the most likely diagnosis?
- What condition could this develop into that causes swelling behind the ear and the ear to stick out/forwards?
- The most likely diagnosis is Acute Otitis Media
- The most likely condition causing swelling behind the ear is mastoiditis. This occurs when the infection spreads from the middle ear cavity into the mastoid. This can lead to the accumulation of pus under tension and resorption of the bony walls and destruction of the air cells (coalescent mastoiditis).
Clinical signs:
- high fever
- headache
- pain posterior to pinna
- profuse discharge from ext auditory canal
- oedematous, erythmatous and tender mastoid
- You are working in emergency and you see a 4 year-old old boy with fever, left otalgia and acute left facial nerve palsy.
What is the most likely diagnosis?
How would you manage this boy?
Most Likely diagnosis Acute otitis media
Management:
• Adequate and regular analgesia is essential
• For most children presenting with acute otitis media initial antibiotics are not indicated
• However children with systemic symptoms should be treated with amoxycillin
• Urgent referral to ENT is required is a suppurative complication develops (e.g. mastoiditis) or facial palsy develops.
May just need appropriate Abx and corticosteroids.
- You are working in emergency and you see a 4 year-old boy with fever, left otalgia and acute left facial nerve palsy.
- What is the most likely diagnosis?
- What dangerous complications can result from this condition?
- The most likely diagnosis is Acute Otitis Media.
- Complications that can result from this condition can be categorised into intratemporal Cx and intracranial Cx.
Intratemporal Cx include:
- hearing loss
- balance and motor problems related to vestibular dysfunction or labyrinthitis
- tympanic membrane abnormalities (middle ear atelectasis, perforation, sclerosis)
- cholesteatoma- recurrent AOM is a risk factor
- MASTOIDITIS
- FACIAL PARALYSIS
- PETROSITIS- ext of infection into petrols bone
Intracranial Cx include:
- meningitis
- brain abscess
- sinus thrombosis which can lead to increased ICP
- subdural empyema (collection of purulentmaerial between the dura and arachnoid membrane- can raise ICP)
- A 65 year-old lady has presented with a lump in her right cheek, centred near the angle of the mandible. What is the differential diagnosis?
Obstructive:
- Sialolithiasis (salivary duct stones)
- Chronic sclerosing sialadenitis (duct infiltrated and scar tissue forms)
- salivary duct stenosis
Neoplastic:
- parotid pleomorphic adenoma (benign)
- Warthin’s tumor (benign cystic tumor)
- parotid adenocarcinoma
- parotid metastases
Infective:
- parotitis
- lymphadenopathy
Inflammatory
- Sjogrens syndrome (AI)
skin:
- lipoma
- epidermoid cyst
- How do you go about assessing a 40 year-old woman who presents with a lump in her lateral neck?
I would keep in mind that In adults over 40, as many as 75% of lateral neck lumps are malignant – In the absence of signs of infection, a lateral neck mass in an adult is lymphadenopathy due to metastatic carcinoma (usually SCC) until proven otherwise.
I would take a detailed history on the lump.
- when it appeared
- pain?
- are there any other lumps?
- infective symptoms?
- head and neck cancer symptoms
- recent infections, bites or trauma
- FHx and other risk factors
- What are the main types of thyroid cancer and what is their prognosis?
Nearly all thyroid cancers originate from thyroid follicular cells and form distinct pathological entities; papillary, follicular and anaplastic. Papillary and follicular are well differentiated with low metastatic potential whereas anaplastic are poorly differentiated and behave aggresively.
Papillary carcinoma constitutes about 2/3 of thryoid cancers in adults and nearly all in children. Peak incidence is between 30-45 years old. The spread is lymphatic and frequently presents with nodal metastases but distal mets are rare. It has a really good prognosis with a 5year survival rate higher than 90%.
Follicular is the 2nd most common thyroid malignancy (10-20% of all thyroid neoplasms).
Typically occurs in those between 40-60 and affects women more (3F:1M). It generally spreads haematogenously to lungs and bones.
It is essentially impossible to distinguish from benign adenomatous hyperplasia on FNAC and histology. Has a prognostic 5 year survival rate of 50-70%.
Aaplastic
• Accounts for 1 – 2% of thyroid malignancies
• Typically occurs in the elderly (6th and 7th decades)
• Presents with a rapidly enlarging diffuse hard thyroid lump, often with symptoms of tracheal or recurrent laryngeal nerve involvement
• Histologically poorly differentiated
• Spread is both lymphatic and haematogenous to lymph nodes, bones brains and lungs
• Poor Prognosis – 5 year survival 5 – 14%
Other thyroid cancers are rarer and include medullary carcinoma and thyroid lymphoma.
Medullary carcinoma:
• Accounts for 5 – 10% of thyroid malignancies
• Occurs in both sporadic (80%) and familial forms
• It sporadic cases it typically peaks in the 3rd and 4th decades
• Presents as a stony hard thyroid lump with possible secondaries in cervical lymph nodes
• Arises from parafollicular C cells of the thyroid, rather than thyrocytes
• Histologically well differentiated tumour with sheets of cells in an amyloid stroma
Has a 5 year survival rate of 70%
Thyroid Lymphoma;
• Accounts for approximately 2.5% of thyroid malignancies
• Typically presents between 50 and 70 years of age
• 3F: 1M
• The aetiology is unclear but Hashimoto’s thyroiditis is a major risk factor
• Excellent prognosis for disease limited to the thyroid- 5 year survival is 85% but this falls to 40% if local spread has occured.
- What are the treatment options for a patient who presents with a toxic goitre (hyperthyroidism associated with an enlarged, overactive thyroid)?
Medical treatment can be achieved via:
- medical treatment
- radioiodine therapy AND
- total or subtotal thyroidectomy.
Medical treatment aims to decrease hormone synthesis and provide symptom control.
- Anti-thyroid drugs are usually 1st line unless pt is elderly or unfit.
Carbimazole is 1st line of therapy OR propylthiouracil can be used if the pt is in 1st trisem of pregnancy or if use is contraindicated due to adverse reaction. Both drugs work by preventing TPO from coupling and iodinating the tyrosine residues on thyroglobulin, and thereby reducing thyroid hormone production.
Unfortunately 34% of pts get reccurence of hyperthyroidism within 2years. - Radio iodide ablation works by thyroid uptake of radioactive iodine leading to destruction of active thyroid tissue. There is a need for thyroxine replacement due to hypothyroidism after treatment
- Thyroidectomy- surgical approach. There is a risk of recurrent laryngeal nerve damage. Thyroxine replacement due to hypothyroidism after treatment.
- Liam was involved in a fight yesterday at the local pub and was slapped in the face. He had a sharp shooting ear pain following the slap and says that he cannot hear too well since then. He also says that he cannot pop his ear drums since that incident. He comes to your practice.
- What is the most likely diagnosis and what will you expect from the examination point of view?
- What will be your advice?
- The most likely diagnosis is traumatic perforation of the tympanic membrane.
From an examination stand point I would expect to find:
- tympanic membrane perforation on otoscopy
- Webbers test would localise to the abnormal ear
- negative rinnes test as bone conduction would be louder than air conduction in affected ear
- may see some bruising of the ext ear OR blood or serous discharge from the ear - My advice would be that the:
- Tympanic membrane usually heals spontaneously and not to worry. BUT WOULD ADVISE TO
- Keep water out of the ear
- Represent if the pain is ongoing or if he feels unwell - Abx if it becomes infected OR FOR ENT REFERRAL
• Follow up otoscopy and audiometry in 4 weeks
• Avoid fights and physical altercations
