Head & Neck Trauma - KSUfac.ksu.edu.sa/sites/default/files/hntraumaforeignbodies.pdf · 2017. 8....
Transcript of Head & Neck Trauma - KSUfac.ksu.edu.sa/sites/default/files/hntraumaforeignbodies.pdf · 2017. 8....
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Head & Neck Trauma Head & Neck Trauma
Dr. Abdulrahman Hagr MBBS FRCS(c)Dr. Abdulrahman Hagr MBBS FRCS(c)Assistant Professor KingAssistant Professor King Saud University Saud University
Otolaryngology ConsultantOtolaryngology ConsultantOtologist, Neurotologist & Skull Base SurgeonOtologist, Neurotologist & Skull Base Surgeon
King Abdulaziz HospitalKing Abdulaziz Hospital
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Mechanisms of TraumaMechanisms of Trauma• MVA• Iatrogenic • Burns and frostbite• Noise• Barotrauma• Lightning
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االحصاءات الصادرة عن وزارة الصحة
2005 ـ 2004عام • على اللجان الطبية الشرعية عرضت قضية 896• قضية منها428صدرت قرارات إدانة في • طبيبا مدعى 848 طبيبا من اصل 299إدانة •
عليهم في المائة من عدد القضايا المنظورة 35 ما يعادل •
10120 العدد 2006 اغسطس 13 هـ 1427 رجـب 19االحـد الشرق االوسط
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Auricle injuriesAuricle injuries• Hematomas
separate the perichondrium (blood supply) from the cartilage
excise fibrous tissue• Apply pressure dressing , drain
• Avulsion: – Reimplantation– Microvascular anastomosis
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Cauliflower EarCauliflower Ear
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Complications of EarComplications of Ear--Piercing Piercing
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Case Case LEFT EAR (AS)
250 500 1000 2000 4000 8000
100
0
10
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1
1
NR IPSI & CONTRA
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HemotympanumHemotympanum
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R
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Longitudinal TB#
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Complications of TB#Complications of TB#• Hearing loss• Vertigo• Tinnitus• Facial paralysis• CSF leak• Carotid injury
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NasoNaso--orbital orbital EthmoidEthmoid and and Frontal Sinus FracturesFrontal Sinus Fractures
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Naso-orbital Ethmoid Fractures
Failure of Diagnosis Leads to Significant Facial Deformities
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SeptalSeptal hematomahematoma
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Nasal Fracture with Septal Hematoma
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Complication Complication Nasal Deformity
– Flattened Nasal Dorsum– Septal Deviation / Dislocation
Intracranial Involvement– Cerebrospinal Fistula– Pneumocephalus
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Goals of ManagementGoals of Management• ABCD• Soft Tissue Repair• Framework Reconstitution
– Nasas Region– Orbital– Nasal Support– Sinus
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Anatomy/Zone IAnatomy/Zone I• Cricoid sternum and clavicles• Contains the
– Subclavian arteries and veins– Dome of the pleura– Esophagus– Great vessels of the neck +recurrent nerve– Trachea
• S/S may be hidden from inspection in the mediastinum or chest
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Anatomy/Zone IIAnatomy/Zone II• Cricoid Angle of the mandible• Contains the
– Larynx– Pharynx– Carotid artery and jugular vein– Phrenic, vagus, and hypoglossal nerves
• Injuries here are seldom occult• Common site of carotid injury
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Anatomy/Zone IIIAnatomy/Zone III• Lies above the angle of the mandible• Contains the
– Internal and external carotid arteries – Vertebral artery– Several cranial nerves
• Vascular and cranial nerve injuries common
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HistoryHistory• Obtain from witnesses, patient• Mechanisms of injury - stab wounds,
gunshot wound, high-energy, low-energy• Estimate of blood loss at scene• Any associated thoracic, abdominal,
extremity injuries • Neurologic history
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Physical ExaminationPhysical Examination• Thorough head and neck exam • Palpation and stethoscope (thrills and bruits)• Neuro exam: mental status, cranial nerves, and
spinal column• Examine the chest, abdomen, and extremities• Be sure to examine the back of the patient as• Don’t blindly explore wound or clamp vessel
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RadiographsRadiographs• CXR - inspiratory/expiratory /Lateral• Cervical spine film to rule out fractures• Soft tissue neck films AP and Lateral• CT Scan • Arteriograms, contrast studies as indicated
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Impending Respiratory FailureImpending Respiratory Failure
• Reduced air entry• Severe work• Cyanosis despite O2
• Irregular breathing / apnea• Altered Consciousness• Diaphoresis
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Intubation: IndicationsIntubation: Indications• Failure to oxygenate• Failure to remove CO2
• Increased WOB• Neuromuscular weakness• CNS failure• Cardiovascular failure
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Laryngeal TraumaLaryngeal Trauma
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IntroductionIntroduction• Functions
– Airway– Voice– Swallowing
• Well protected (mandible, sternum)• Support: Hyoid, thyroid, cricoid• Outcome determined by initial
management
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Mechanism of InjuryMechanism of Injury• Blunt
– MVA, strangulation, clothesline, sports related– Significant internal damage, minimal signs
• Penetrating – GSW: damage related to velocity– Knife: easy to underestimate damage
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Initial EvaluationInitial Evaluation• ATLS principles ABCD• Secure airway – local tracheotomy• Intubation can worsen airway• Avoid cricothyroidotomy• Pediatric: tracheotomy over bronchoscope• Clear C-spine
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HistoryHistory• Change in voice – most reliable• Dysphagia• Odynophagia• Difficulty breathing - more severe injury• Anterior neck pain• Hemoptysis
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Signs of Respiratory DistressSigns of Respiratory Distress• Tachypnea• Tachycardia• Grunting • Stridor• Head bobbing• Flaring• Inability to lie
down• Agitation
•• RetractionsRetractions•• Access musclesAccess muscles•• WheezingWheezing•• SweatingSweating•• Prolonged Prolonged
expirationexpiration•• Pulsus paradoxusPulsus paradoxus•• ApneaApnea•• CyanosisCyanosis
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Physical examPhysical exam• Stridor • Hoarseness• Subcutaneous emphysema• Laryngeal tenderness, ecchymosis, edema• Loss of thyroid cartilage prominence• Associated injuries - vascular, cervical spine,
esophageal
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Physical ExamPhysical Exam
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Flexible Flexible FiberopticFiberoptic LaryngoscopyLaryngoscopy
• Perform in emergency room• Findings dictate next step
– CT scan– Tracheotomy– Endoscopic– Surgical Exploration– Other studies
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Laryngoscopic Exam
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Radiographic ImagingRadiographic Imaging
• C-spine• CXR• CT • Angiography• Contrast esophagrams
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CT ScanCT Scan
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CT Scan
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Laryngeal TraumaAsymptomatic or minimal symptoms
F/L
CT scan
Mild EdemaSmall hematoma
Non-displaced linear fractureIntact mucosa
Small lacerations
Displaced fracture (by CT or exam)
Loss of mucosa or extensivelacerationBleeding
Exposed cartilage
Bed restCool mistAntibioticsSteroids
Anti-reflux
Tracheotomy
Panendoscopy
Explore
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Laryngeal TraumaRespiratory distress, open wounds, bleeding
Tracheotomy
Panendoscopy
Explore
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Laryngeal Framework Repair
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Laryngeal Framework Repair
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Treatment GoalsTreatment Goals• Preservation of airway• Prevention of aspiration• Restoration of normal voice
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NINI--SNHLSNHL• 30 Y saudi solder• Lt ear tinittus• Can not sleep• Severe depresion
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Trauma & SNHLTrauma & SNHL•• NISNHLNISNHL•• Acoustic traumaAcoustic trauma•• BarotraumaBarotrauma
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Noise induce SNHL• Boilermaker's deafness • one of the most common occupationally
induced disabilities• (OSHA) Occupational Health and Safety
Administration• Tinnitus
– commonly accompanied NISNHL– warning sign
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Noise induce SNHLNoise induce SNHL• Usually is limited to 3, 4, and 6 kHz • 4 kHz Greatest loss ? • ?Susceptibility
– Age, gender, race, and coexisting vascular disease Not been shown to correlate with susceptibility to NIHL
– No known way to predict susceptibility
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TTS TTS vsvs PTS PTS • Temporary threshold shift
(TTS) HL recovers over the next 24
to 48 hours
• Permanent threshold shift(PTS)
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9898• 90 db for 8 hours • 95 db for 4 hours• 100 db for 2 hours• 105 db for 1 hours
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Primary role of Primary role of otolaryngologistsotolaryngologists
• Prevention • Early identification.
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BarotraumaBarotrauma• Injury of the TM and middle ear • Unequalized pressure differentials between
the middle and external ears • Flying or underwater diving• ETD may predispose
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S/S• Pain• H.L• hyperemia and possible TM perforation • Edema and ecchymosis of the ME mucosa• Conductive hearing loss • Hemotympanum• Transudative middle ear effusion
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Foreign Bodies of the Aerodigestive Tract
Dr. Abdulrahman Hagr MBBS FRCS(c)Dr. Abdulrahman Hagr MBBS FRCS(c)Assistant Professor KingAssistant Professor King Saud University Saud University
Otolaryngology ConsultantOtolaryngology ConsultantOtologist, Neurotologist & Skull Base SurgeonOtologist, Neurotologist & Skull Base Surgeon
King Abdulaziz HospitalKing Abdulaziz Hospital
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Foreign BodiesForeign Bodies• Foreign body ingestion• Foreign body aspiration• Toddlers
– Oral exploration– Easy distractibility– Cognitive development
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Foreign Body IngestionForeign Body Ingestion• Coins • Meat• Vegetable matter• Less than 24 hours in most
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Foreign Body AspirationForeign Body Aspiration• Parental suspicion• History
• Choking• Gagging• Wheezing• Hoarseness• Dysphonia
• Can mimic asthma, croup, pneumonia• “A positive history must never be ignored, while a
negative history may be misleading”
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Foreign Body AspirationForeign Body Aspiration• Physical exam
– Larynx/cervical trachea• Inspiratory or biphasic stridor
– Intrathoracic trachea• Prolonged expiratory wheeze
– Bronchi• Unequal breath sounds• Diagnostic triad - <50%
– Unilateral wheeze– Cough– Ipsilaterally diminished breath sounds
• Fiberoptic laryngoscopy
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Flexible Flexible LaryngoscopyLaryngoscopy
• Proper Equipment• Assess nares/choanae• Assess adenoid and
lingual tonsil• Assess TVC mobility• Assess laryngeal
structures
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RadiologyRadiology• Plain films:
– Chest and airway AP and lat– Expiratory films
• Fluoroscopy• Barium Swallow• CT, MRI, Angiography
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Direct Laryngoscopy
• Insufflation technique:
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• 5y• Unilateral discharge• Foul smell
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Foreign Body IngestionForeign Body Ingestion• Disc batteries
– Emergency (Alkaline > Acid )– NaOH, KOH, mercury
• 1 hour – mucosal damage• 2 to 4 hours – muscular layers• 8 to 12 hours – perforation
– Esophagoscopy– Observation for gastric location for 4-7 days– Laparotomy for bowel perforation
?
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Foreign Body IngestionForeign Body Ingestion• Common locations
– Cricopharyngeus– Aorta/left mainstem bronchus– Gastroesophageal junction
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Foreign Body IngestionForeign Body Ingestion• Radiopaque
– Coins– Cartilage/bones
• Radiolucent– Hot dogs
• Barium swallow
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Foreign Body IngestionForeign Body Ingestion• Barium Swallow
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Foreign Body IngestionForeign Body Ingestion
• Removal– General anesthesia– Intubated– Esophagoscopy– Examine for ulceration/perforation
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Foreign Body IngestionForeign Body Ingestion• Postoperative management• NPO for 4-12 hours• Perforation
– Tachycardia– Tachypnea– Fever– Chest pain
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Foreign Body AspirationForeign Body Aspiration
• Radiography– PA & lateral views of chest & neck– Inspiration & expiration– Lateral decubitus views– Airway fluoroscopy
• 25% have normal radiography
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Foreign Body AspirationForeign Body Aspiration
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Foreign Body AspirationForeign Body Aspiration
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Foreign Body Aspiration
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Foreign Body Aspiration
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Foreign Body Aspiration
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Foreign Body AspirationForeign Body Aspiration• Postoperative Care
– Chest physiotherapy for retained secretions– Antibiotics
• Not routinely used
– Steroids• Not routinely used• Traumatic insertion or removal
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Foreign Body AspirationForeign Body Aspiration• Complications
– Pneumonia• Antibiotics, physiotherapy
– Atelectasis• Expectant management, physiotherapy
– Pneumothorax– Pneumomediastinum
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Examine both ears Examine both ears
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What do you think?What do you think?• 3 y old• Lt side discharge• Foul smell
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