may well mask the underlying bony deformity, and if there is initial doubt about
whether surgical manipulation is necessary, patients should be examined again
after this interval. Radiography should be carried out. Both a lateral and an
anteroposterior view should be taken. In a lateral X-ray it can be difficult to
differentiate between an undisplaced fracture of the nasal tip and the vascular
markings on a normal nasal bone, hence the importance of taking an
anteroposterior view as well. It can also be difficult to ascertain whether the
fracture line is new, or related to a previous injury.
Clinical examination. In looking for a deviated fracture of the nasal bones, the
examiner should stand behind the patient with the latter's head thrown back,
when asymmetry is more easily demonstrated. The patient's profile should also be
examined for evidence of depression or hump formation. Anterior rhinoscopy
should be carried out to ascertain the patency of the airways and to note any
damage to the septum such as dislocation, haematoma or abscess formation. As
nasal injuries may be associated with facial fractures, the eyes should be
routinely examined for diplopia, the orbital rim palpated for step deformity,
and sensation tested over the area of skin supplied by the infra-orbital nerve.
Palpation of the nasal bones themselves should be done very gently, and pain
will be evoked, if a fracture is present, up to 3 weeks from the original
injury.
Treatment. Treatment of fractured nasal bones with cosmetic deformity is
manipulation. This can be done immediately, before the swelling occurs, as on
the sports field, when firm pressure may be enough to reduce the fracture. The
next optimum period for manipulation is about 10 days after the injury, when the
soft-tissue swelling will have resolved, but the nasal bones are still mobile.
After 3 weeks, the callus formation is sufficient to make manipulation
impossible, and the patient should be reviewed in 6 month, when, if active
treatment is still required, a formal rhinoplasty is carried out.
The nasal bones are disimpacted and manipulated with special forceps, and, of
equal importance, an attempt should be made to reposition the septal cartilage
in the midline. If there is instability in the corrected position, a plaster of
Paris cast or tin splint should be applied for a period of 10 days. Anterior
nasal packing is introduced.
Epistaxis associated with nasal injures is usually short-lived and settles with
simple pressure. Occasionally it may be troublesome and recurrent, especially if
there is an associated fracture of the ethmoidal area.
If the fracture is compound to the skin, the wound should be cleaned and
sutured, and the patient given systemic antibiotics and antitetanus prophylaxis.
Nasal septal haematoma and abscess
A haematoma of the nasal septum may be secondary to trauma or may follow septal
surgery. The blood collects in the subperichondrial layers and is bilateral.
This results in a smooth firm swelling of the septum causing bilateral nasal
obstruction. Infection frequently supervenes, and an abscess occurs. This is
associated with considerable pain in the region of the nasal tip, which becomes
excruciating on manipulation of the nose. If an abscess forms the patient
complains of headache and fever.
A septal haematoma should be evacuated with an adequate incision on both sides
of the cartilage, and removal of all blood clot. The nose is thereafter packed
for 24 hours to prevent reaccumulation of blood. If an abscess is encountered,
incisions are again made on both sides of the septum, the pus is removed and a
drain is stitched to the incision to aid drainage and to prevent premature
closure of the incision. The appropriate systemic antibiotic is also given. As
the perichondrial layer carries the blood supply to the cartilage, in a
proportion of cases a septal abscess results in resorption of the quadrilateral
(septal) cartilage and a saddle deformity of the nose develops with a
perforation of the nasal septum.
LARYNX TRAUMATOLOGY
The function of the larynx may be affected by vocal abuse, intubation injury,
external trauma, chemical toxins, and foreign bodies.
The symptoms are dictated by the abnormal laryngeal function and include voice
disorders, respiratory obstruction, coughing, and surgical emphysema of the
neck.
The appropriate endoscopic and radiologic procedures must be used to diagnose
and localize the lesion.
Vocal Abuse
Acute
Symptoms. These include dysphonia, or even aphonia, and pain on speaking.
Pathogenesis. This is caused by extreme overuse of the voice in sporting
spectators, politicians, market traders, and disco habitues.
Diagnosis. Indirect or direct laryngoscopy which shows hyperemia or swelling of
the vocal cords and subepithelial bleeding.
Treatment. Strict voice rest and inhalations are required. If polyps form, they
are removed by microlaryngoscopy.
Chronic
Symptoms. The voice is hoarse and croaking or disappears under stress. Singing
is difficult or impossible.
Pathogenesis. Screamer's or singer's nodules develop because of chronic overuse
or misuse of the voice.
Screamer's nodules occur in children and are frequent in mothers of large
families and in teachers who must talk a lot.
Singer's nodes are due to unsatisfactory singing technique.
Diagnosis. Direct or indirect laryngoscopy shows the nodules on the typical site
at the junction between the anterior and middle thirds of the vocal cords which
is the point of maximal amplitude of the vibrations of the vocal cords. They are
usually bilateral.
Treatment. Once the nodules progress beyond a certain size, they become
fibrotic, and voice rest and speech therapy are no longer successful. Most
patients then require endolaryngeal microsurgery with postoperative speech
therapy.
Intubation Injury
Acute
Symptoms. Immediately or shortly after removal of the tube the patient complains
of dysphonia, attacks of coughing, and hemoptysis. He also has a pain in the
larynx and neck.
Pathogenesis. Injury is caused by repeated or incorrect intubation, intermittent
positive pressure respiration, a protruding guide wire, a wrong-sized tube,
insufficient relaxation, overextension, and pressure of the tube cuff. These
factors lead to a myogenic or neurologic paralysis. Drying of the mucosa due to
the premedication facilitates mucosal injury. Laryngeal complications may be
expected in adults after less than 48 h of intubation, whereas in young children
the average time interval for the onset of mucosal injuries is between 3 and 7
days.
Diagnosis. Laryngoscopy shows a subepithelial hematoma, superficial and deep
mucosal injuries, and rarely a tear of the vocal cord or subluxation of the
arytenoid cartilage.
Treatment. A hematoma or a superficial mucosal lesion can heal spontaneously
within a few days. Pressure paralysis of the recurrent laryngeal nerve is also
capable of spontaneous resolution, but tears of the vocal cord or subluxation of
the arytenoid cartilage require surgery.
Chronic
Symptoms. Dysphonia or laryngeal dyspnea develop 2 or 8 weeks after intubation
anesthesia or prolonged intubation.
Pathogenesis. Incorrect intubation, a tube that is too large or too rigid,
incorrect (endolaryngeal or subglottic) position of the cuff, or prolonged
intubation can all cause damage. The general condition of the patient including
factors such as shock, retching, and vomiting are additional factors.
The early lesions including endolaryngeal or subglottic hyperemia and edema,
ischemic mucosal defects with fibrinous membrane, necrosis and ulceration lead
to late injures. The latter include ulceration, perichondritis, cartilaginous
necrosis, synechiae, and strictures.
Diagnosis. This is made by laryngoscopy, tomography, and pulmonary function
studies. An intubation granuloma is usually bilateral and lies on the vocal
process, vocal cords, mucosa of the subglottic space.
Treatment. Granulomas are removed by endolaryngeal microsurgery or laser.
Postoperative speech therapy is indicated, but there is a tendency for
recurrence.
External Trauma
Blunt and penetrating injuries, and open and closed injuries, occur and must be
diagnosed.
Symptoms. These include immediate or increasing dyspnea, even complete
respiratory obstruction due to hematoma, edema, and dislocation of cartilage
fragments, bleeding, and dysphonia. Dysphagia and pain occur when the esophagus
is affected.
Pathogenesis. These injuries are particularly common in traffic accidents,
especially due to impact with the steering wheel and dashboard. Other causes
include athletic injuries, Karate blows. fighting, and attempting strangulation.
In addition to the direct trauma resulting in subluxation and disruption of the
laryngeal framework, the blow may force the larynx against the vertebral column
causing endolaryngeal mucosal tears and vertical, horizontal, or combined
fractures. Subluxation of the larynx from the trachea can occur. Perforations or
contusions in the neighboring hypopharynx and upper esophagus lead to
tracheoesophageal or laryngoesophageal fistulas. The neighboring nerves and
vessels may also be injured.
Diagnosis. Inspection, palpation, and laryngoscopy demonstrate fractures,
crepitation, or displacement of laryngeal fragments and surgical emphysema of
the neck. Tomography and pulmonary function tests should also be carried out.
Treatment. Preservation of the airway is the most important measure,
if necessary by bronchoscopy, tracheotomy, or intubation, Emergency
bronchoscopy may be used with bronchoscopes of the appropriate size. Distressing
attacks of coughing are suppressed by codeine preparations. Some patients may
require admission to the intensive care unit, e.g., for treatment of shock, for
infusions, or transfusions, etc. Further procedures are shown in the table.
Type and Treatment of Laryngeal Trauma
Type of InjuryTreatment
Basic principle is to secure a free airway
Hematoma and edema. Small tears of the mucosa.
Extensive soft tissue injuries of the neck, exposed cartilage with
otherwise intact or easily reconstructable laryngeal skeleton.
Loss of thyroid cartilage and mucosa.
Laryngeal fractures, vertical or horizontal.
Laryngotracheal subluxation.
Late stenosis.
Voice rest, inhalation, steroids, tracheotomy if necessary.
Open exploration and reconstruction.
Mucosal grafts and stenting of the inside of the larynx.
Suturing of the fragments with or without stenting.
End-to-end anastomosis of the stumps.
Open exploration, excision of scar, mucosal or cartilaginous grafts and
stenting.
Inhalational Trauma by Chemical Toxins
Symptoms. Acute symptoms include severe attacks of coughing, a feeling of
burning and asphyxia, and epiphora. Chronic symptoms include hoarseness, a
feeling of dryness, clearing the throat, and coughing attacks.
Pathogenesis. The cause is escaping gases or steam after explosions of
industrial chemicals and the effect of smoke in fires. The most common chronic
toxin is inhalation of tobacco smoke.
Diagnosis. Laryngoscopy shows redness, mucosal maceration, and edema.
Treatment. Voice rest, giving up smoking, humidification of the air,
corticosteroids for edema, inhalation therapy, and laryngoscopic follow-up are
indicated.
Alkali and acid burns and scalds of the pharynx
Scalds occur in children especially. Alkali and acid burns due to mistaking the
contents of a bottle (lye, vinegar essence, cleaning fluids, etc. kept in empty
bottles) or to suicidal attempts (hydrochloric acid, caustic soda, vinegar
essence, sulfuric acid) occur principally in adults.
Symptoms. They are dramatic. There is severe pain in the mouth and pharynx,
sialorrhea, difficulty in swallowing, redness and vesicle formation on the
affected part of the mucosa, and later a flat white membrane with deep red edges
and mucosal edema appears. Caustic substances are usually swallowed so that the
mucosa of the esophagus, the stomach, and the intestine may also be involved.
The patient may be in shock.
Diagnosis. The history and local findings in the mouth, pharynx, and perioral
tissues form the basis for the diagnosis. Involvement of the stomach and
esophagus must be assessed as rapidly as possible by careful endoscopy. The type
of fluid and the amount must be determined, and if possible the ingested fluid
should be tested.
Treatment. It includes drinking large amounts of water or, even better, milk.
The acids are neutralized by sodium bicarbonate or magnesium salts. Lyes are
neutralized by diluted vinegar or lemon juice. Treatment of shock may be needed.
Local treatment of the mouth and pharynx includes lozenges or ice cubes,
lukewarm mouthwashes possibly with Lidocaine supplements, analgesics, cool
liquid diet, feeding by a nasogastric tube, or parenteral nutrition in severe
cases, antibiotics, and steroids, depending on local findings.
Burns of the esophagus by acid or lye
Symptoms. There is a typical history of initially very severe pain in the mouth,
the pharynx, behind the sternum, and in the epigastrium. There is retching,
vomiting, sialorrhea, and at times glottic edema and dyspnea. White corrosive
crusts and burned areas are to be found in the mouth and the surrounding area.
Shock becomes progressive with falling blood pressure and rising pulse, cyanosis
and pallor, cold sweats, and circulatory collapse. Later, perhaps in 24 to 48 h,
there are increasing signs of intoxication such as renal damage, hematuria,
evidence of liver damage, hemolysis, disturbance of electrolyte and water
metabolism, and occasionally involvement of the central nervous system (CNS).
There is increasing risk of perforation or mediastinitis, pleuritis,
peritonitis, and tracheoesophageal fistula. Rapid wasting occurs. If the patient
survives, dysphagia gradually sets in due to stricture formation.
Pathogenesis. The coagulation necrosis due to acids and colliquative necrosis
due to lyes penetrates to varying depths. The corrosive scars in the mouth and
pharynx may he minimal because of rapid passage, with severe degrees extending
into the esophagus and possibly the stomach and intestine. The esophagus is more
severely afflicted than the stomach in lye burns because of reflex cardiospasm.
In acid burns the stomach is more severely affected.
The time course is as follows: (1) primary local necrosis in the mouth, pharynx,
esophagus, stomach, and intestine; (2) generalized intoxication; (3) acute,
subacute, and chronic corrosive esophagitis; (4) healing of the esophagitis with
scarring or stricture; (5) late complications such as late or restenosis and
possibly malignant degeneration. The scar tissue stenosis begins about the 3rd
week.
Diagnosis. It is made from the typical history of an accident or suicide and the
typical local findings. The corrosive substance must be identified. Radiographs
are taken of the thorax and abdomen. If the corrosive burns appear to be mild,
contrast views of the esophagus are taken and a careful esophagoscopy may be
done to allow the esophagus and stomach to be examined and a feeding tube to be
introduced. Contraindications include shock and suspected perforation. Immediate
esophagoscopy is only carried out if the degree and extent of the corrosive burn
are not clear.
Treatment. If possible, large quantities of fluids such as milk, oil, etc.
should be drunk. The juice of citrus fruits or dilute 2% vinegar are given for
lye burns; magnesium oxide and antacids are given for acid burns but must be
given within 2 h. Analgesics and sedatives are given, and the patient is
admitted to an intensive care unit for intravenous management of shock,
administration of fluids, parenteral feeding, broad-spectrum antibiotics, and if
necessary gastrostomy and tracheotomy. High-dose steroids are given
intravenously.
The first careful esophagoscopy is carried out after 6 to 8 days. Dilatation can
begin at the end of the 2nd week if the radiographs and endoscopy show the
formation of a stricture. Follow-up esophagoscopies are carried out at intervals
of 10 days until mucosal defects are epithelialized. The patient is then checked
by radiography and esophagoscopy after 1, 3, 6, and 12 months.
Technique of bouginage. Two methods are available:
Early bouginage about 8 to 12 days after the burn using a thick bougie of about
14 mm in adults, 6,5 mm in children, and 10 mm in adolescents, increasing daily
in caliber until the patient can swallow without difficulty. The intervals are
then prolonged until the stenoses can no longer be demonstrated by radiography.
Late bouginage. This may only occur several weeks later.
Bouginage may take several weeks. The goal of treatment by bouginage in adults
is to achieve an esophageal lumen of about 15 mm diameter, about 10 to 12 mm in
children up to 10 years, and 10 to 14 mm in adolescents.
Dangers of bouginage include perforation of the esophageal wall. This does not
occur using the bouginage over a thread. Perforations tend to occur particularly
in the area of the necrotic stricture, in blind pouches, etc. and cause
mediastinitis, pleuritis, or peritonitis which must be drained externally.
If treatment by bouginage is unsatisfactory, operative treatment of the
stricture, partial esophageal resection and replacement by a segment of stomach
or bowel, must be considered. Because of the tendency to restenosis and to
malignant degeneration in old age, patients with esophageal strictures must be
kept under medical supervision by radiography and endosoopy at increasing
intervals.
FOREIGN BODIES IN THE EARS
Foreign bodies, both animate and inanimate, may be found in the ear. The latter
are much more frequently found, and especially so in children, and are often
introduced by the patients themselves. Inanimate objects may be divided into
those which swell with moisture, such as peas and beans, and those which do not
swell, such as beads, buttons or shells. Foreign bodies rarely cause any trouble
unless the tympanic membrane has been injured, and they may remain undetected
for years. Most complications result from ill-directed attempts at removal.
Gentle inspection will reveal the object in most cases. If it is not seen the
ear may be gently syringed, because a very small foreign body may lie out of
sight in the meatal floor, beyond the isthmus and close to the drum. When the
foreign body is seen and determined not to be of vegetable composition, removal
may be effected by syringing. The stream should be directed along that part of
the meatal wall where there is the widest space between it and the foreign body.
While the removal of a foreign body may be easily accomplished when it has not
been driven in by ill-directed interference, great difficulties may be presented
in cases of impaction, or when the object has become swollen from absorption of
fluid, or if the meatal walls have become inflamed. Such cases are best treated
in hospital. In cases of impaction it is sometimes possible to withdraw the
object by means of a fine hook. The use of forceps is inadvisable except in the
case of small or thin objects, because the jaws of the forceps often cause the
foreign body to slide further into the meatus. Some objects may be removed by
suction, a suitable catheter being used.
Attempts at removal of foreign bodies in children should not be prolonged,
because of the pain produced and the fright engendered. In such cases, and in
all cases when the object lies beyond the isthmus, it is wiser to remove it
under a general anaesthetic, often with the use of the operating microscope.
If the walls of the meatus are swollen and bleeding, it is advisable, before
operating, to insert a strip of 12 mm ribbon gauze soaked in a adrenaline
hydrochloride. Should a diffuse inflammation of the meatus have been set up by
attempts at removal, it may be best to treat the inflammation before attempting
removal. In rare instances repeated attempts at removal may have driven the
object into the middle ear, and an external operation will be required for its
extraction.
Animate foreign bodies in the external meatus are not rarely. Maggots cause
intense pain, and their presence is most likely in an ear where discharge is
already present, and which has become very offensive and bloodstained. It is
useless to attempt to syringe them out as they are firmly attached to the meatal
walls. Chloroform water or vapour must be applied to the external meatus in
order to anaesthetize or kill the maggots and so release their grip on the skin.
Thereafter they may be removed by syringing.
FOREIGN BODIES IN THE NOSE
Children, especially young children aged 2 or 3 years, frequently push foreign
bodies into the nose. Such objects may be classified as organic and inorganic.
Inorganic foreign bodies include metal objects, buttons, beads, plastic objects,
etc. These may lie undetected for many weeks, giving rise to no symptoms and
occasionally are found accidentally during routine examination. Organic foreign
bodies, such as wood, paper, cotton wool or foam rubber, produce a local
inflammatory reaction which may proceed to the formation of granulation tissue.
There is a nasal discharge from the affected side, and this quickly becomes
purulent and foul-smelling, and may be bloodstained. The object may swell with
the absorption of moisture from the mucus, but pain is seldom complained of.
In the early stage the object is situated just within the nostril and is easily
seen. In time it moves further into the nasal cavity - possibly due to the
child's habit of sniffing or possibly because it is pushed further in - and it
becomes encased with mucus, or mucopus if the object is organic in origin. In
this event it may not be seen because of the mucopus or the inflammatory
swelling of the mucous membrane.
Removal of the foreign body may be easy if it lies in the nostril. It may be
flicked out with a probe, or by getting the child to smell pepper and on closing
the opposite nostril it may be sneezed out. When the object reaches the nasal
cavity and becomes covered with secretions it becomes slippery and not easy to
grasp. A child may sit through one attempt at removal but if this fails, and
especially if the attempt produces bleeding, he is not likely to endure a
second. Accordingly it is wiser to give the child an anaesthetic for the removal
if one attempt has been made or if the object is situated far back at the
initial inspection. The anaesthetic need only be a short one for removal is
usually easily accomplished either with cupped forceps or with a metal probe,
the distal 5 mm of which have been bent to a right angle. The probe is passed,
point downwards, above the object which is pressed to the floor of the nose and
then raked out. The probe may fail with such a narrow object as a shirt button
because it slips, or with foam rubber which has become adherent to the mucosa.
In these cases the use of cup-shaped forceps is preferable. Very occasionally
the foreign body may be of such an irregular shape that it cannot be brought out
through the anterior naris, and it may have to be pushed gently into the
nasopharynx and recovered from there. The surgeon must be alive to the
possibility that there is a second foreign body present, either in the same side
or in the opposite one, and after removal of the object the nose must be
examined for this.
RHINOLITHS
Rhinoliths are calcareous masses which are occasionally found in the nose. They
may be found in one side only or they may be bilateral. The deposit of salts,
chiefly calcium and magnesium carbonates and phosphates, takes place around a
nucleus which may be organic or inorganic, and the nucleus may be a foreign body
or merely dried secretions of blood and mucus. Their presence must be considered
in any long-standing cases of nasal discharge
Symptoms. These are nasal obstruction and discharge, but if the rhinoliths have
been present for some time they may give rise to considerable destruction of the
nasal mucosa with the formation of sequestra of cartilage or bone, and the
development of an extremely unpleasant odour. Rhinoliths may attain a
considerable size and are often irregular in shape. The diagnosis is usually
easily made by inspection, but if there is any doubt palpation with a probe will
disclose the rough hard object.
Treatment. The treatment is removal under local or general anaesthesia. The
rhinolith may be too large to remove in a single piece and it may require to be
broken with a strong pair of forceps before removal in fragments. There is a
brisk haemorrhage during the removal, and it may require packing with ribbon
gauze for 2-4 hours.
FOREIGN BODIES IN THE PHARYNX
These are less common in the mouth and pharynx than in the esophagus. Small
pointed foreign bodies, such as splinters of bone, fish bones, bristles from a
toothbrush, needles, nails, or bits of wood and glass, impact in the tonsil, the
base of the tongue, the vallecula, or the lateral wall of the pharynx. Larger
foreign bodies, e.g., bits of toys, flat bones, coins, buttons, large fish
bones, bits of false teeth, etc. often impact in the piriform sinus or
hypopharynx before entering the esophagus.
Symptoms. There is pain of varying severity which is worse on swallowing, and
swallowing may be completely obstructed.
Diagnosis. It is based on the history, if the material is suspected to be
radiopaque, radiography is carried out. Radiographically, a swallow is also
carried out with a contrast medium using a colorless medium (not barium!) which
will not influence assessment of the mucosa at subsequent endoscopy. Endoscopy
is then carried out. Small impacted foreign bodies in the tonsil or base of the
tongue are often felt with the finger. Small foreign bodies in the upper pharynx
are best removed without endoscopy, using grasping forceps under direct vision.
Treatment. Instrumental extraction of the foreign body is performed as quickly
as possible because of the danger of pressure necrosis or mucosal injury causing
abscess or mediastinitis.
If a foreign body is suspected, endoscopy should be carried out as quickly as
possible using an open rigid esophagoscope. The search must be continued until
the foreign body is found or until it is certain that no foreign body is
present. Attempts to dislodge foreign bodies by eating foods such as bread is
not justifiable because this often leads to delay and allows complications to
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