E N T – EMERGENCIES E N T – EMERGENCIES HEAD & NECKHEAD & NECK

TRAUMATRAUMA

Bambang HariwiyantoBambang Hariwiyanto

Epistaxis :Epistaxis :

History:History: Other bleeding Other bleeding Bilateral bleeding Bilateral bleeding

Systemic disorderSystemic disorder

Leukemia.Leukemia.

Hereditary blood dyscrasiasHereditary blood dyscrasias

Trauma/anticoagulant agent.Trauma/anticoagulant agent.

Localization :Localization :• Kisselbach’s Plexus / Anterior Epistaxis Kisselbach’s Plexus / Anterior Epistaxis

Anterior part of Septum nasal,Anterior part of Septum nasal, Not profuse.Not profuse.

Management :Management :

1.1. Treat locally.( Anterior tampon )Treat locally.( Anterior tampon )

2.2. Avoid local trauma.Avoid local trauma.

• Posterior Epistaxis :Posterior Epistaxis : Old patients.Old patients. Hypertensi.Hypertensi. Blood through mouth. / hematemesis.Blood through mouth. / hematemesis. Diffuse / Profuse.Diffuse / Profuse. Tumor : Yuvenile Angiofibroma Tumor : Yuvenile Angiofibroma

nasopharynxnasopharynxManagements :Managements :1.1. Posterior Tamponade nasal / Belloque Posterior Tamponade nasal / Belloque

tampon if bleeding profuse.tampon if bleeding profuse.2.2. Control blood pressure.Control blood pressure.3.3. Ro / CT scan.Ro / CT scan.

Tampon belloque

Otogenic meningitisOtogenic meningitis Etiology :Etiology :

• Chronic Suppurative Otitis Media.Chronic Suppurative Otitis Media. Haemophilus influenzae.Haemophilus influenzae. Streptococcus pnemoniae.Streptococcus pnemoniae. Neisseria Meningitidis.Neisseria Meningitidis.

• Skull base fracture.Skull base fracture. Symptoms :Symptoms :

• Fever , headacheFever , headache• Nausea, photopobia.Nausea, photopobia.• Neck stiffness.Neck stiffness.• other neurologycal symptoms : pupilloedema.other neurologycal symptoms : pupilloedema.

Treatment :Treatment :• AntibioticaAntibiotica• Mastoidectomy.Mastoidectomy.

Complications of otomastoiditis.

Head & neck traumaHead & neck trauma• Maxillofacial traumaMaxillofacial trauma

Mandible fractureMandible fracture Maxilla fractureMaxilla fracture

• Le Forte ILe Forte I• Le Forte IILe Forte II• Le Forte IIILe Forte III

• Neck / laryngeal traumaNeck / laryngeal trauma External traumaExternal trauma Internal traumaInternal trauma

Laryngeal traumaLaryngeal trauma External trauma :External trauma :

• Blunt trauma :Blunt trauma : Traffic accidents.Traffic accidents. Recreational / sport accidentsRecreational / sport accidents

• Penetrating trauma :Penetrating trauma : Increasing of violent crime :Increasing of violent crime :

• Shot gun injuries.Shot gun injuries.• Knives injuries.Knives injuries.

Internal traumaInternal trauma• Burn.Burn.• Intubation tube.Intubation tube.

-Blunt trauma :

-Traffic accident

-Motor race

-Unlimited speed

-Recreational / sport accidents

-Boxing / karate

-Seat belt awareness

Chemical – Corrosive traumaChemical – Corrosive trauma

History and examination :History and examination : Type, concentration, quantity, form and duration of Type, concentration, quantity, form and duration of

contact / caustic agent.contact / caustic agent. Acids : Coagulation, necrosis.Acids : Coagulation, necrosis. Alkalis : penetrative, necrosis, vascular trombosis.Alkalis : penetrative, necrosis, vascular trombosis.

Status airway.Status airway. Burn of the face, lips or oral cavity.Burn of the face, lips or oral cavity. Sign and symptoms of air way obstruction, Sign and symptoms of air way obstruction,

mediastinitis, peritonitis and acid base mediastinitis, peritonitis and acid base imbalance must not bee overlooked.imbalance must not bee overlooked.

Broad spectrum antibiotic and Broad spectrum antibiotic and steroid.steroid.

Nutrition parenterally.Nutrition parenterally. Classified of Esophageal burn :Classified of Esophageal burn :

• 1. Mucosal erythema and edema.1. Mucosal erythema and edema.• 2. Trans mucosal injury.2. Trans mucosal injury.• 3. Trans mural injury.3. Trans mural injury.

Penetrating trauma :

- Increasing of violent crime :

-Shot gun injuries

-Knives injuries.

Anatomical considerations :Anatomical considerations :

Function of Larynx :Function of Larynx :• Airway / passageway Airway / passageway

respiration.respiration.• Phonatory.Phonatory.• Protection.Protection.• Fixation.Fixation.

Protected from injuries by :Protected from injuries by :• MandibleMandible• Sternum & Clavicle.Sternum & Clavicle.• Mobility of laryngeal trachea Mobility of laryngeal trachea

cartilages.cartilages.• Elasticity of the fibrous Elasticity of the fibrous

connective tissueconnective tissue

Pathophysiology of external trauma Pathophysiology of external trauma

Displaced of cartilage fragments Displaced of cartilage fragments with edges exposed to the lumen of with edges exposed to the lumen of larynx. larynx.

Collapse of the cricoid cartilage.Collapse of the cricoid cartilage. Immediate airway collapse requiring Immediate airway collapse requiring

urgent tracheostomy.urgent tracheostomy.

Point of impact in laryngeal injuriea

Effect of forces applied to the laryngotracheal Effect of forces applied to the laryngotracheal

1.1. Fracture of the hyoid bone.Fracture of the hyoid bone.• Laceration /distortion of epiglottis.Laceration /distortion of epiglottis.• Some times airway obstruction .Some times airway obstruction .• Lead to chronic stenosis of the airway. (seldom) Lead to chronic stenosis of the airway. (seldom)

Effect of forces applied to the laryngotracheal

2.Separated hyoid from thyroid cartilage.

•Dislocated of epiglottis

•Damage of thyrohyoid membrane.

3.Fracture of thyroid cartilage complex

•Severe disruption of the laryngeal interior.

•Caused exposed cartilage edges to appear in the lumen.

4.4. Force to criciohyroid membrane.Force to criciohyroid membrane.•Most serious and subtle injuries.Most serious and subtle injuries.

•Dislocating of cricothyroid joint.Dislocating of cricothyroid joint.•Laryngeal stenosis.Laryngeal stenosis.

5. Blow at this point :5. Blow at this point :•Destruction of the cricoid Destruction of the cricoid cartilage cartilage

•Collaps.Collaps.•Stenosis with very difficult to repair.Stenosis with very difficult to repair.

Injuries at this point :Injuries at this point :• Separation of the trachea between tracheal Separation of the trachea between tracheal

rings or at cricotracheal junctionrings or at cricotracheal junction

Penetrating neck injuries :Penetrating neck injuries :

Three horizontal zonesThree horizontal zones• Zone I :Zone I :

Comprises the root of the inferior the neck Comprises the root of the inferior the neck to the inferior border of cricoid cartilage.to the inferior border of cricoid cartilage.

• Zone II : Zone II : Consist of the neck between the angle of the Consist of the neck between the angle of the

mandible and the cricoid cartilage.mandible and the cricoid cartilage.

• Zone III :Zone III : Comprises the neck superior to the angle Comprises the neck superior to the angle

mandible up to the skull base.mandible up to the skull base.

Zone III

Zone II

Zone I

Zone I injuries :Zone I injuries : Potentially lethal.Potentially lethal.

• Great vessels.Great vessels.• Cervical & thoracic esophagus.Cervical & thoracic esophagus.

> 1/3 are asymptomatic at the > 1/3 are asymptomatic at the presentation.presentation.

MANDATORYMANDATORY :: Angiography of the Aortic arc and great Angiography of the Aortic arc and great

vessels.vessels. Esophageal evaluation mediastinitis / Esophageal evaluation mediastinitis /

sepsis.sepsis.

Zone II injuries:Zone II injuries:• The largest area.The largest area.• The most common site of entry in The most common site of entry in

penetrating trauma.penetrating trauma. Larynx and trachea.Larynx and trachea. The internal Yugular vein.The internal Yugular vein. The internal/external and Common Carotis The internal/external and Common Carotis Subclavian artery.Subclavian artery.

Neck Exploration !!! :Neck Exploration !!! :• Followed by ancillary testing :Followed by ancillary testing :

Angiography.Angiography. Serial examinations every 6 hours.Serial examinations every 6 hours.

Zone III injuriesZone III injuries

Potential for injuries to major blood Potential for injuries to major blood vessels and the cranial nerves at vessels and the cranial nerves at /near base skull/near base skull

> ¼ of patients with arterial injuries > ¼ of patients with arterial injuries asymptomatic at presentation.asymptomatic at presentation.

Diagnosis Sign Symptoms Test Diagnosis Sign Symptoms Test

---------------------------------------------------------------------- ---------------------------------------------------------------------- Vascular injuries Shock Angiogram Vascular injuries Shock Angiogram

Hematoma Neck exploration Hematoma Neck exploration

Hemorraghe Hemorraghe

Pulse deficitPulse deficit

Neurologuc deficit.Neurologuc deficit.

Laryngeal injuriesLaryngeal injuries Subcutaneus emphysemaSubcutaneus emphysema Laryngotrachesoscopy Laryngotrachesoscopy

Airway obstructionAirway obstruction Neck exploration Neck exploration

HemoptysisHemoptysis Computed Tomografi. Computed Tomografi.

DyspneaDyspnea

StridorStridor

Hoarseness / dysphonia.Hoarseness / dysphonia.

Pharynx/Esophagus injuries Subcutaneus emphysemaPharynx/Esophagus injuries Subcutaneus emphysema Contrast Contrast esophagogram.esophagogram.

HematemesisHematemesis Esophagoscopy Esophagoscopy

Dysphagia / odynophagiDysphagia / odynophagi Neck exploration. Neck exploration.

Diagnosis Penetrating Neck Trauma

Complications of penetrating face and Complications of penetrating face and neck injuries:neck injuries:

Neck Injuries :Neck Injuries :• Airway obstruction.Airway obstruction.• Pharyngocutaneus fistula.Pharyngocutaneus fistula.• Neck abscess / mediastinitis.Neck abscess / mediastinitis.• Vocal cords paralysis.Vocal cords paralysis.• Cervical spine osteomyelitis. Cervical spine osteomyelitis.

Facial Injuries :Facial Injuries :• Blindness / visual lossBlindness / visual loss• Diplopia.Diplopia.• Facial nerve paralysis.Facial nerve paralysis.• Nasal obstruction.Nasal obstruction.• Malocclusion / trismusMalocclusion / trismus• Orbital cellulitis etc.Orbital cellulitis etc.

Management of traumaManagement of trauma

A : Airway and spine assessment.A : Airway and spine assessment. B : Breathing.B : Breathing. C : Circulation.C : Circulation. D: Disability and neurological D: Disability and neurological status.status. E :Exposure and overall evaluation E :Exposure and overall evaluation for other injuries.for other injuries.

Tracheostomy :Tracheostomy :

Def :Def :• Opening through to the trachea.Opening through to the trachea.

Indication :Indication :• Relief upper airway from the obstruction.Relief upper airway from the obstruction.

Caused by :Caused by :• Congenital disease.Congenital disease.• Infection.Infection.• Trauma.Trauma.• Neoplasma.Neoplasma.• Etc.Etc.

• Prolonged intubationProlonged intubation

Suggested readingSuggested reading

Bailey J.B. 2001. Head and Neck Bailey J.B. 2001. Head and Neck Surgery-Otolaryngology. Lippincot Surgery-Otolaryngology. Lippincot Williams & Wilkins.Williams & Wilkins.

Lee K.J. 2003. Essential Otolaryngo-Lee K.J. 2003. Essential Otolaryngo-

logy. McGraw-Hill.logy. McGraw-Hill. Jones A.W. Jones A.W. et al.et al.1998. Diseases of 1998. Diseases of

the Head & Neck, Nose and Throat. the Head & Neck, Nose and Throat. Oxford University PressOxford University Press