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Surgery for Finals Series: Nose and Laryngology Lavandan Jegatheeswaran Ear Nose and Throat Surgery Core Surgical Trainee 1Social MediasThe NoseFunctions • Allows air entry • Filters and cleans air to remove particles and allergens • Provides a sense of smell • Warms and moistens air Case 1 Question You are asked to review a 45M in ED who presents with right sided epistaxis. He does not report any trauma to the nose. His PMH consists of hypertension, AF and a previous metallic aortic valve. His epistaxis is still ongoing despite 20 mins of trying to stem the bleeding. He is normally independent of ADLs. A. Pack nose, admit, hold anticoagulants and reverse INR A/ Patent E/ B. Pack nose, admit, continue B/ anticoagulants and nil reversal of INR Sats 95% OA C. Pack nose, send home, reverse INR, hold anticoagulants and bring back in RR 23 morning to clinic C/ HR 110 Irregular GCS 15 D. Pack nose, send home, nil reversal of BP 100/70 BM 7.0 Oropharynx – dried INR, continue anticoagulants and bring CRT 4 seconds PEARL trail of blood on the back in morning to clinic HS I + II + 0 Temp 37.0 right E. Pack nose, admit, continue anticoagulants and reverse INR Case 1 Answer What is the most likely cause? The high potential to bleed with the patient A. Pack nose, admit, hold anticoagulants and reverse INR taking an anticoagulant for his metallic B. Pack nose, admit, continue valve and AF means that this patient should anticoagulants and nil reversal ofbe packed and admitted. The thrombotic C. Pack nose, send home, reverse risk caused by reversing the INR and holding INR, hold anticoagulants and the anticoagulants is higher than the bring back in morning to clinic D. Pack nose, send home, nil bleeding risk posed by this scenario. The reversal of INR, continue thrombotic risk may result in valve anticoagulants and bring back in thrombosis and failure which is associated morning to clinic with significant morbidity and mortality. E. anticoagulants and reverse INRCase 1 Explanation Case 1 Explanation • Management • Acute • First aid initially • A-E assessment • Bloods including FBC, G+S x2 and Coag • 1g TXA stat • Topical adrenaline • Nasal packing if nil stopping • Nasal cautery • Surgery if uncontrolled bleeding – SPA/ECA ligation • Long term • Address risk factors • Hypertension • Anticoagulants • Naseptin cream (beware of peanut allergy) • Nasal cautery in clinic or on ward Case 2 Question nose highly suspicious for a nasal bone fracture. Patient reports getting into an altercation with a fist whilst drunk in the early hours of the morning. There is nil evidence of head injury and there is nil evidence of septal haematoma or epistaxis. A. CT facial bones, admit for reduction B. CT facial bones, bring back in one week for reduction in clinic C. XR facial bones, bring back in one week for reduction in clinic D. Nil scan and admit for reduction E. reduction in clinick in one week for Case 2 Answer How would you manage this patient? There is nil indication for radiology to solely A. CT facial bones, admit for reduction diagnose nasal bone fractures – this is a B. CT facial bones, bring back in onelinical diagnosis. week for reduction in clinic Patients are advised to return to clinic with C. XR facial bones and admit for manipulation under anaesthetic being reduction performed 7-14 days after the injury (allows D. Nil scan and admit for reduction for swelling to subside). E. Nil scan, bring back in one week for reduction in clinic Case 2 Explanation • Most common type of facial skeleton fracture • History: • Deformity • Nasal obstruction • Rhinorrhoea • Olfactory disturbance • Epistaxis • Examination: • Nasal soft tissue swelling and ecchymosis • Ocular contusions • Columellar dislocation • Nasal bone crepitus • Nasal bone deviation and/or dislocation • Septal cartilage deviation and/or dislocation Case 2 Explanation • Management • Maniupulation under Anaesthetic • Local first usually • General reserved for failure under local or children • Septorhinoplasty • If cosmetic concerns or affecting breathing Case 3 Question nose highly suspicious for a nasal bone fracture. He reports being punched in the face at the club last night. Patient reports that he did have a short period of epistaxis which resolved with basic first aid. Clinically his nose does appear to be fractured. Patient also reports that his nose feels blocked a few hours after the injury occurred. A. Septal perforation B. Septal haematoma C. Septal abscess D. Normal nose E. Septal deviation Case 3 Answer What is your primary diagnosis? Worsening bilateral nasal obstruction after A. Septal perforation nasal trauma should immediately raise the B. Septal haematoma suspicion of a septal haematoma. It is C. Septal abscess diagnosed clinically on direct anterior D. Normal nose rhinoscopy. Can be either unilateral or E. Septal deviation bilateral. Tends to appear as a fluctuant red looking mass on the septum. A septal perforation will appear as a hole in the medial aspect part of the nose (the septum) A septal abscess is possible but highly unlikely given the duration of symptoms that this If a unilateral lump was noted, then septal deviation would be a differential however in this case with the history of recent trauma and symptoms, this will not be considered as a differential. Case 3 Explanation • Haematoma between nasal septum and overlying mucoperichondrium • Pressure related ischaemia and necrosis of septum • Can cause septal perforations, abscesses and saddle nose deformity • Management • Incision and drainage within 24 hrs • GA for children • LA for adults • IV antibiotics to prevent septal complications • Post operative antibiotics to prevent formation of septal abscess Case 4 Question 1. 30M who presents following a boxing match with clear fluid from his nose. He reports headaches and light headedness especially on standing 2. 20F who reports worsening nasal discharge and blockage. Shenulamatosis with polyangitis tends to get this every spring and summer. She has B.en Aspirin exacerbated respiratory symptoms but now do not improveight. This initially helpdisease 3. 15M reports a long history of nasal blockage and post nasalergic rhinitis drip. PMH – sensitivity to NSAIDs and asthma. Feels like nasal blockage gets worse with NSAIDs D. Rhinitis medicamentosa E. Cerebrospinal fluid leak 4. 40M presents with a long history of nasal discharge, blockage and crusting. PMH hearing loss and is on peritoneal dialysis. 5. 25M who presents with seasonal nasal discharge – worse in the spring and summer months. Well otherwise. Also reports having eczema and asthma Case 4 Answer 1. 30M who presents following a boxing match with E. Cerebrospinal fluid leak clear fluid from his nose. He reports headaches and light headedness especially on standing 2. 20F who reports worsening nasal discharge and blockage. She tends to get this every spring and D. Rhinitis medicamentosa summer. She has been using Otrivine for 4 weeks straight. This initially helped the symptoms but now do not improve 3. 15M reports a long history of nasal blockage. B. Aspirin exacerbated respiratory PMH – sensitivity to NSAIDs and asthma. Feels like nasal blockage gets worse with NSAIDs disease 4. 40M presents with a long history of nasal A. Granulamatosis with polyangitis discharge, blockage and crusting. PMH hearing loss and is on peritoneal dialysis. 5. 25M who presents with seasonal nasal discharge C. Allergic rhinitis – worse in the spring and summer months. Well otherwise. Also reports having eczema and asthma Case 4 Explanation • Granulamatosis with polyangitis – systemic condition. ENT complications involve hearing loss, nasal crusting, epistaxis, facial pain. Generally can cause renal failure and shortness of breath. Managed with immunomodulatory drugs and steroids • Aspirin exacerbated respiratory disease – remember Samter’s triad: aspirin sensitive asthma, recurrent sinonasal disease with nasal polyposis and sensitivity to aspirin and other non-steroidal anti-inflammatory drugs • Allergic rhinitis – Mast cell degranulation and allergic response to pollen or other common allergens. Cause conjunctivitis, rhinitis and irritation. Managed with decongestants, anti histamines, mast cell stabilisers. • Rhinitis medicamentosa – associated with chronic use of nasal decongestants e.g. Otrivine. Symptoms initially improve on starting but then worsen. Advise patient to stop chronic usage. • Cerebrospinal fluid leak – associated with trauma and basal skull fractures. Test fluid using beta 2 transferrin (gold standard). In case of non surgical (70% of CSF leaks stop)asures for 7 days to decrease intracranial pressure Case 5 Question not report any visual disturbances. They reported having facial pain and greeney do discharge from their nose for a week prior to this event and is still on going. She does not have any focal neurological deficits. She has a CT taken of her sinuses and orbits. A. Orbital cellulitis B. Facial cellulitis C. Angioedema D. Peri-orbital cellulitis E. Exophathalmus Case 5 Answer How would you manage this The presence of cellulitis and oedema patient? around the eyes and the lack of opthalmic A. Orbital cellulitis symptoms points towards a diagnosis of B. Facial cellulitis peri-orbital cellulitis. C. Angioedema D. Peri-orbital cellulitis E. Exophathalmus Orbital cellulitis may present with similar symptoms and also key ophthalmic signs including colour vision loss, decreased ROM and changes in visual acuity. Facial cellulitis can cause peri-orbital cellulitis but the clear history of sinusitis prior to the presence of this patient’s symptoms. Angioedema causes bilateral peri-orbital swelling. Exophathalmus is a key sign associated with Graves Disease and affects both eyes Case 5 Explanation • Perioribital cellulitis – involvement of eyelids and structures surrounding the eye but NOT the eye • Orbital cellulitis – infective inflammation of the orbit – OPTHALMOLOGY EMERGENCY • Clinical Features • Unilateral eyelid swelling and erythema • Unilateral eye pain/tenderness • Fever/malaise/irritability • Ptosis • Consider history of foreign body or traumatic eye injury • History of sinusitis • Assessment • Assessment of eye movements (if unable to open eye, will need hospital assessment) • Visual acuity (using a Snellen chart, dependent on age) • Assessment of cranial nerves, including pupillary responses • General systemic exam Case 5 Explanation • Chandler Grading – based on clinical and radiological findings Case 5 Explanation • Red Flags • Painful/restricted eye movements • Visual impairment • Reduced acuity • Relative afferent pupil defect (RAPD) • Diplopia • Loss of colour vision (use Ishihara plates to assess for colour deficiency) • Chemosis • Proptosis • Severe headache or other features of intracranial involvement • General malaise/fever • Inability to assess eye movements as unable to open the eye • Baby in neonatal period – due to risk of chlamydia or gonococcal infection, needing specific swabs and treatment. Case 5 Explanation • Management • Antibiotics • Analgesia • Ophthalmology review to rule out orbital cellulitis • CT sinus + orbit for all children • CT sinus + orbit in adults with evidence of orbital cellulitisThe LarynxThe Vocal Cords Case 6 Question raise her voice. She reports she has been quite stressed at work recently and that her current cohort of Year 7 students have been quite rowdy in the classroom. She is a non smoker and she does not drink alcohol. A FNE is performed which shows the following. She is fit and well otherwise. A. Laryngeal papillomatosis B. Vocal cord nodules C. Glottic cancer D. Laryngopharyngeal reflux E. Reinke’s oedema Case 6 Answer What is your primary diagnosis? Characteristic history of singer/teacher A. Laryngeal papillomatosis (occupations that require the raising of B. Vocal cord nodules voice) presenting with hoarse voice tends to C. Glottic cancer be associated with vocal cord nodules. Voice D. Laryngopharyngeal reflux abuse is the main cause for vocal cord E. Reinke’s oedema nodules. Laryngeal papillomatosis is caused by HPV and will be disseminated throughout the larynx. Glottic cancer tends to be unilateral in foci (unless direct invasion) and is associated with immobility of the vocal cords and extension beyond which is not seen on the FNE. Laryngopharyngeal reflux tends to make the larynx look swollen and oedomatous. Reinke’s oedema is associated with smoking not voice abuse. Case 6 Explanation • Benign growths • Risk factors • Voice abuse (think teachers/singers etc) • Chronic cough • Reflux • Allergies • Usually found on the between anterior 1/3 and middle 1/3 of vocal rd cords • Management • SALT and voice therapy • Microsurgery • Laser excision • Medical management of risk factors Case 7 Question worse over the past year. She reports that she is currently being investigated for unusual vaginal bleeding. She does not report any lumps in her neck and reports that she feels like her breathing is getting worse. She also reports that she has never been vaccinated. She has a FNE performed which shows the following: A. Laryngeal papillomatosis B. Vocal cord nodules C. Glottic cancer D. Supraglottic cancer E. Subglottic cancer Case 7 Answer What is your primary diagnosis? A history of HPV and being unvaccinated A. Laryngeal papillomatosis alongside hoarse voice and the findings of B. Vocal cord nodules papillomas on FNE is diagnostic for laryngeal C. Glottic cancer papillomatosis. D. Supraglottic cancer E. Subglottic cancer Laryngeal cancer tend to appear ragged and will have elements of neovasculature and so will be friable to touch. The papilloma visible on the FNE have smooth surfaces. Case 7 Explanation • Development of small papillomas (wart like structures) in larynx • Caused by HPV 6, 11, 16 and 18 • Symptoms: • Hoarse raspy voice (most common) • Chronic cough • Dysphagia • Dyspnoea • Globus sensation • Choking episodes • Can eventually obstruct airway if left untreated • Management • Surgical • Cold steel ideally • Laser excision • Tracheostomy – last resort as can push disease into lungs • Some evidence of antivirals Case 8 Question of alcohol a week and has a 25 pack year history of smoking. PMH – GORD,s a 15 units gastritis, melanoma (excised) and HTN. She reports generally feeling well in self but is concerned by the deepening of her voice. There are no issues with her breathing. A. Reinke’s Oedema B. Laryngopharyngeal reflux C. Pyriform fossae cancer D. Glottic cancer E. Vocal cord polyp Case 8 Answer What is your primary diagnosis? The appearance of a swollen oedeomatous A. Reinke’s Oedema bilateral vocal cords is synonymous with B. Laryngopharyngeal reflux Reinke’s oedema. The long history of C. Pyriform fossae cancer smoking and GORD are risk factors for D. Glottic cancer Reinke’s oedema to develop. E. Vocal cord polyp There are no concerning or irregular masses present on the FNE which rules out cancer. A vocal cord polyp has a similar pathophysiology to vocal cord nodules and will be present in a similar location to that. LPR causes oedema of the larynx but is also associated with a lot of secretions around the entrance to the larynx. Case 8 Explanation • Swelling in Reinke’s space • Change in a vocal fold causes change in vocal fold vibration • The vocal fold swelling makes the superficial lamina propria (Reinke’s space) stiff, thus reducing vocal fold vibration – hence voice changes and/or problems • Typically occurs in middle-aged/post-menopausal women who have a long-term history of smoking cigarettes • Causes • Smoking • LPR • Voice abuse • Management • SALT and voice therapy • Medical management of underlying causes • SurgeryThank you O O F Feedback & Instagram + 3FC N O Please complete feedback to receive CF slides! 3 NH O Cl CH3 CH OH CH 3 3 CH OH 3 3C CH3 HC O 3