1.

EAR

FOREIGN BODY TEMPORAL BONE FRACTURE EPISTAXIS SEPTAL HEMATOMA AIRWAY OBSTRUCTION

2.

NOSE

3.

THROAT

Insects Cotton, paper, organic material (seeds) Small batteries Toys Beads, stones

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

Workup: No specific laboratory or radiologic studies Pysical examination is the main diagnostic tool
the object seen on direct

visualization or otoscopic examination.

Management Insect should be killed prior to removal, using mineral oil or lidocaine (2%). EMLA cream also effective. Irrigation, suction is the method of foreign body 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.

If infection or abrasion is occur, fill the ear canal 5 times/day for 5-7 days with a combination antibiotic and steroid otic suspension (eg, Cortisporin or Cipro HC).

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.

Hearing loss: conductive or sensorineural Dizziness Facial weakness or paralysis (7% overall) Otorrhea Rhinorrhea More rare: facial numbness and diplopia

Hemotympanum Battles sign: postauricular ecchymosis Raccoon sign: periorbital ecchymosis

Ulrichs Classification (1926) Longitudinal fractures Transverse fractures

The commonest type accounting 80% of all the temporal 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 squamous portion of the temporal bone, extends through the postero superior portion of the external auditory canal, continues across the roof of the middle ear space, anterior to labyrinth to end anteromedially in the middle cranial fossa close to foramen lacerum and ovale.

1. Bleeding from external canal due to laceration of skin and ear drum 2. Haemotympanum (conductive deafness) 3. Fractures involving the bony portion of external canal 4. Ossicular chain disruption causing conductive deafness. 5. Facial palsy (rare) 20% usually at the level of horizontal segment distal to geniculate ganglion 6. CSF otorrhoea (usually temporary) 7. Sensorineural hearing loss can occur due to consussion

Comprises about 20% of all temporal bone fractures. Usually caused by frontal or parietal blow, rarely by occipital blow. The fracture lines runs at right angle to the long axis of the petrous pyramid. Usually it starts in the middle cranial fossa close to foramen lacerum, it crosses the petrous pyramid transeversely to end at the foramen magnum.

1. Sensorineural hearing loss due to damage to 8th cranial nerve 2. Facial palsy due to damage of facial nerve 3. Vertigo 4. Labyrinthitis ossificans (this should be borne in mind before performing cochlear implant in these patient)

FEATURE
Incidence Mechanism CSF otorrhea Tympanic membrane perforation Facial nerve damage

LONGITUDINAL
Approximately 80% Temporal or parietal trauma Common Common 20% (most often temporary and frequently delayed in onset) Common (conductive type and possibly high tone neurosensorial) Common (associated with otorrhagia) Common (spontaneous, less intense) Common Common (less intense)

TRANSVERSE
Approximately 20% Frontal or occipital trauma Occasional Rare 50% (severe, usually permanent, and immediate in onset) Common (severe sensorineural or mixed) Possible (not associated with otorrhagia) Common (spontaneous, intense) Rare Common (intense)

Hearing loss

Hemotympanum Nystagmus Otorrhagia Vertigo

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 planes must be performed. Bone window cuts would be really useful Also indicated when surgical intervention for otologic complications following temporal bone fracture becomes necessary Indicated in patients with persistent cranial nerve injuries following skull base fracture.

CT angiography Indicated in evaluation of petrous carotid artery MRI Helps in identification of intralabyrinthine haemorrhage, brain stem injury and nerve compression

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

Meningocele/encephalocele
Can manifest as a late onset CSF otorrhea,

unilateral clear middle ear effusion, or recurrent meningitis. 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.

Management;
ABC, AMPLE HISTORY. PRIMARY SURVEY HEAD AND NECK EXAM CRANIAL NERVES

Medical treatment:

Stabilize the pt condition Patient with delayed facial paralysis is managed conservatively with 10-14 days of systemic corticosteroids unless medically contraindicated.

Surgical treatment

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

Epistaxis = bleeding from the nasal cavity

Is a sign, not a disease!

Nasal septum
Internal carotid: ant. ethmoidal a. post. ethmoidal a. External carotid: splenopalatine a. greater palatine a. superior labial a.

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.

Anterior
Kesselbachs Plexus

Posterior
Woodruffs Plexus

Local cause Trauma Infection Foreign body

General cause CVS Disorder of blood and blood vessel Liver disease

Atmospheric changes
Deviated septum Juvenile angiofibroma

Kidney disease
Drugs Acute general infection

Initial first-aid Assessment of blood loss Evaluation of cause history taking Procedure to stop bleeding

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

Cauterisation

@nose bridge Suck ice and put at the palate

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

electrocautery

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

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

Collection of blood b/w cartilage septum & mucoperichondrium Most often associated with fracture Dx: grape-like, blue bulge that obstructs nares

Left untreated: can cause saddle nose deformity

Treatment
Prompt aspiration /

drainage to prevent saddle nose

Packing / splinting Prophylactic anitbiotics Tetanus prn

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

The epiglottis is a cartilaginous structure covered with mucous membrane Epiglottitis is an acute inflammation of the epiglottis and pharyngeal structures Can be severe life threatening disease

Age 3-7 yrs old H. influenzae type B, Group A Streptococcus Triad of drooling, dysphagia, and distress. High fever Positioning- tripod position Dyspnea/ Inspiratory stridor/ accessory muscle use / muffled voice Brassy cough

CBC: leukocytosis Film lateral neck thumb shaped epiglottis Avoid tongue depressor Controlled intubation Intravenous ATB

Secure airway with endotracheal intubation. Might need cricothyroidotomy. Child should sit upright Humidified oxygen Hospitalization No tongue blades IV antibiotics:Ceftriaxone (Rocephin) cefotaxime (Ceftin), Ampicillin with chloramphenicol

Evaluate for extubation 24-48 hours post intubation. 24-48 hours post extubation Rifampin prophylaxis for 4days for household contacts if: children in household have not been vaccinated with the entire series

Emergency tracheostomy in the case of upper airways obstruction 1. Tumor in the larynx 2. Trauma of the larynx 3. Bilateral vocal cord paralysis 4. F.B. in the larynx after failure of Heimlichs manuver