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Head & Neck Trauma
Dr. Mohammad aloulah, MBBS, SBORL(c)Assistant Professor King Saud University
Otolaryngology Consultantl
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Mechanisms of Trauma
• MVA• Iatrogenic
• Burns and frostbite• Noise
• Barotrauma
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Auricle injuries• Hematomas
separate the perichondrium (bloodsupply) from the cartilageÆexcise fibrous tissue• Apply pressure dressing , drain
• Avulsion:- Reimplantation
- Microvascular anastomosis
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Cauliflower Ear
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Complications of Ear-Piercing
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Case LEFT EAR (AS)
250 500 1000 2000 4000 8000
0
10
20
30
40
50
60
70
80
90NR IPSI & CONTRA
100 1
110 1
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Hemotympanum
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R
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Longitudinal TB#
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Complications of TB#• Hearing loss
• Vertigo
• Tinnitus
• Facial paralysis
• CSF leak
• Carotid injury
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Naso-orbital Ethmoid andFrontal Sinus Fractures
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Naso-orbital Ethmoid Fractures
Failure of DiagnosisLeads to SignificantFacial Deformities
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Septal hematoma
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Nasal Fracture with Septal Hematoma
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ComplicationNasal Deformity
- Flattened Nasal Dorsum
- Septal Deviation / Dislocation
Intracranial Involvement- Cerebrospinal Fistula
- Pneumocephalus
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Goals of Management• ABC
• Soft Tissue Repair
• Framework Reconstitution- Nasas Region
- Orbital
- Nasal Support
- Sinus
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Anatomy/Zone I• Cricoid Æ 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 themediastinum or chest
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Anatomy/Zone II• Cricoid Æ 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 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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History• 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 Examination
• Thorough head and neck exam
• Palpation and stethoscope (thrills and bruits)
• Neuro exam: mental status, cranial nerves, andspinal 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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Radiographs• 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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Intubation: Indications
• Failure to oxygenate
• Failure to remove CO2
• Increased WOB
• Neuromuscular weakness
• CNS failure
• Cardiovascular failure
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Laryngeal Trauma
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Introduction• Functions
- Airway- Voice
- Swallowing
• Well protected (mandible, sternum)• Support: Hyoid, thyroid, cricoid• Outcome determined by initial
management
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Mechanism 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 Evaluation• ABC
• Secure airway - local tracheotomy
• Intubation can worsen airway• Avoid cricothyroidotomy
• Pediatric: tracheotomy over bronchoscope
• Clear C-spine
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History• Change in voice - most reliable
• Dysphagia
• Odynophagia
• Difficulty breathing - more severe injury
• Anterior neck pain
• Hemoptysis
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Signs of Respiratory Distress
• Tachypnea• Tachycardia
• Grunting• Stridor
• Head bobbing• Flaring
• Inability to liedown• Agitation
• Retractions• Access muscles
• Wheezing• Sweating
• Prolongedexpiration
• Pulsus paradoxus• Apnea
• Cyanosis
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Physical 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 Exam
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Flexible Fiberoptic Laryngoscopy
• 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 Imaging
• C-spine
• CXR
• CT• Angiography
• Contrast esophagrams
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CT Scan
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CT Scan
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Laryngeal TraumaAsymptomatic or minimal symptoms
F/L
CT scan
Displaced fractureMild Edema
Small hematomaNon-displaced linear fracture
Intact mucosaSmall lacerations
Bed restCool mistAntibioticsSteroids
Anti-reflux
(by CT or exam)Loss of mucosa or extensive
lacerationBleeding
Exposed cartilage
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 Goals• Preservation of airway
• Prevention of aspiration• Restoration of normal voice
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NI-SNHL• 30 Y saudi solder
• Lt ear tinittus
• Can not sleep
• Severe depresion
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Trauma & SNHL• NISNHL
• Acoustic trauma• Barotrauma
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Noise induce SNHL
• one of the most common occupationallyinduced disabilities
• Tinnitus- commonly accompanied NISNHL
- warning sign
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Noise induce SNHL• Usually is limited to 3, 4, and 6 kHz
• 4 kHz Greatest loss ?
• ?Susceptibility- Age, gender, race, and coexistingvascular disease Not been shown tocorrelate with susceptibility to NIHL
- No known way to predictsusceptibility
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TTS vs PTS• Temporary threshold shift(TTS)
HL recovers over the next 24to 48 hours
• Permanent threshold shift(PTS)
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98• 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 otolaryngologists
• Prevention
• Early identification.
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Barotrauma• Injury of the TM and middle ear
• Unequalized pressure differentials betweenthe 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 theAerodigestive Tract
Dr. Mohammad Aloulah ,MBBS. SBORLAssistant Professor King Saud University
Otolaryngology Consultant King Abdulaziz Hospital
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Foreign Bodies• Foreign body ingestion
• Foreign body aspiration
• Kids- Oral exploration
- Easy distractibility
- Cognitive development
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Foreign Body Ingestion• Coins
• Meat
• Vegetable matter
• Less than 24 hours in most
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Foreign Body Aspiration• Parental suspicion
• History• Choking• Gagging
• Wheezing• Hoarseness• Dysphonia
• Can mimic asthma, croup, pneumonia
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Foreign 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 Laryngoscopy
• Proper Equipment
• Assess nares/choanae
• Assess adenoid andlingual tonsil
• Assess TVC mobility
• Assess laryngealstructures
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Radiology• Plain films:
- Chest and airway AP and lat
- Expiratory films
• Fluoroscopy
• Barium Swallow
• CT, MRI, Angiography
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Direct Laryngoscopy
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• 5y
• Unilateral discharge
• Foul smell
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Foreign 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
- Laparotomy for bowel perforation
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Foreign Body Ingestion• Common locations
- Cricopharyngeus
- Aorta/left mainstem bronchus
- Gastroesophageal junction
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Foreign Body Ingestion
• Radiopaque- Coins
- Cartilage/bones
• Radiolucent- Hot dogs
• Barium swallow
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Foreign Body Ingestion
• Barium Swallow
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Foreign Body Ingestion
• Removal- General anesthesia
- Intubated
- Esophagoscopy
- Examine for ulceration/perforation
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Foreign Body Ingestion• Postoperative management
• NPO for 4-12 hours
• Perforation- Tachycardia
- Tachypnea
- Fever
- Chest pain
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Foreign 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 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 Aspiration
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Foreign 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 Aspiration• Complications
- Pneumonia• Antibiotics, physiotherapy
- Atelectasis• Expectant management, physiotherapy
- Pneumothorax
- Pneumomediastinum
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Examine both ears
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What do you think?• 3 y old
• Lt side discharge
• Foul smell
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