E N T EMERGENCIES

HEAD & NECK

TRAUMA
Bambang Hariwiyanto

Epistaxis :

History:

Other bleeding
Bilateral bleeding
Systemic disorder
Leukemia.
Hereditary blood dyscrasias
Trauma/anticoagulant agent.

Localization :

Kisselbachs Plexus / Anterior Epistaxis

Anterior part of Septum nasal,

Not profuse.
Management :
1.
Treat locally.( Anterior tampon )
2.
Avoid local trauma.

 Posterior Epistaxis :
Old patients.

Hypertensi.

Blood through mouth. / hematemesis.

Diffuse / Profuse.

Tumor : Yuvenile Angiofibroma

nasopharynx
Managements :
1. Posterior Tamponade nasal / Belloque
tampon if bleeding profuse.
2. Control blood pressure.
3. Ro / CT scan.

Tampon belloque

Otogenic meningitis

Etiology :

Chronic Suppurative Otitis Media.

Haemophilus influenzae.
Streptococcus pnemoniae.
Neisseria Meningitidis.

Skull base fracture.

Symptoms :

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

Treatment :

Antibiotica
Mastoidectomy.

Complications of otomastoiditis.

Head & neck trauma

Maxillofacial trauma
Mandible fracture
Maxilla fracture

Le Forte
Le Forte
Le Forte

I
II
III

Neck / laryngeal trauma

External trauma
Internal trauma

Laryngeal trauma
External trauma :
Blunt trauma :
Traffic accidents.
Recreational / sport accidents

Penetrating trauma :

Increasing of violent crime :

Shot gun injuries.
Knives injuries.

Internal trauma
Burn.
Intubation tube.

-Blunt trauma :
-Traffic accident
-Motor race
-Unlimited speed
-Seat belt awareness
-Recreational / sport accidents
-Boxing / karate

Chemical Corrosive trauma

History and examination :

Type, concentration, quantity, form and duration of

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

Status airway.
Burn of the face, lips or oral cavity.
Sign and symptoms of air way obstruction,
mediastinitis, peritonitis and acid base
imbalance must not bee overlooked.

Broad spectrum antibiotic and

steroid.
Nutrition parenterally.
Classified of Esophageal burn :
1.
2.
3.

Mucosal erythema and edema.

Trans mucosal injury.
Trans mural injury.

Penetrating trauma :
- Increasing of violent crime :
-Shot gun injuries
-Knives injuries.

Anatomical considerations :

Function of Larynx :
Airway / passageway
respiration.
Phonatory.
Protection.
Fixation.

Protected from injuries by :

Mandible
Sternum & Clavicle.
Mobility of laryngeal trachea
cartilages.
Elasticity of the fibrous
connective tissue

Pathophysiology of external trauma

Displaced of cartilage fragments

with edges exposed to the lumen of
larynx.
Collapse of the cricoid cartilage.
Immediate airway collapse requiring
urgent tracheostomy.

Point of impact in laryngeal injuriea

Effect of forces applied to the laryngotracheal

1.
Fracture of the hyoid bone.

Laceration /distortion of epiglottis.

Some times airway obstruction .
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. Force to criciohyroid membrane.

Most serious and subtle injuries.

Dislocating of cricothyroid joint.
Laryngeal stenosis.

5. Blow at this point :

Destruction of the cricoid

cartilage
Collaps.
Stenosis with very difficult to repair.

Injuries at this point :

Separation of the trachea between tracheal
rings or at cricotracheal junction

Penetrating neck injuries :

Three horizontal zones

Zone I :

Comprises the root of the inferior the neck

to the inferior border of cricoid cartilage.

Zone II :

Consist of the neck between the angle of the

mandible and the cricoid cartilage.

Zone III :

Comprises the neck superior to the angle

mandible up to the skull base.

Zone III

Zone II
Zone I

Zone I injuries :

Potentially lethal.

Great vessels.
Cervical & thoracic esophagus.

> 1/3 are asymptomatic at the

presentation.
MANDATORY :
Angiography of the Aortic arc and great
vessels.
Esophageal evaluation
mediastinitis / sepsis.

Zone II injuries:
The largest area.
The most common site of entry in
penetrating trauma.
Larynx and trachea.
The internal Yugular vein.
The internal/external and Common Carotis
Subclavian artery.

Neck Exploration !!! :

Followed by ancillary testing :
Angiography.
Serial examinations every 6 hours.

Zone III injuries

Potential for injuries to major blood

vessels and the cranial nerves at
/near base skull
> of patients with arterial injuries
asymptomatic at presentation.

Diagnosis Penetrating Neck Trauma

Diagnosis
Sign Symptoms
Test
---------------------------------------------------------------------Vascular injuries

Shock
Hematoma

Angiogram
Neck exploration

Hemorraghe
Pulse deficit
Neurologuc deficit.
Laryngeal injuries Subcutaneus emphysema
Laryngotrachesoscopy
Airway obstruction
Neck exploration
Hemoptysis
Computed Tomografi.
Dyspnea
Stridor
Hoarseness / dysphonia.
Pharynx/Esophagus injuries
Subcutaneus emphysema
Contrast
esophagogram.
Hematemesis
Esophagoscopy
Dysphagia / odynophagi
Neck exploration.

Complications of penetrating face and

neck injuries:

Neck Injuries :

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

Facial Injuries :

Blindness / visual loss

Diplopia.
Facial nerve paralysis.
Nasal obstruction.
Malocclusion / trismus
Orbital cellulitis etc.

Management of trauma

A : Airway and spine assessment.

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

Tracheostomy :

Def :
Opening through to the trachea.

Indication :
Relief upper airway from the obstruction.

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

Prolonged intubation

Suggested reading

Bailey J.B. 2001. Head and Neck

Surgery-Otolaryngology. Lippincot
Williams & Wilkins.
Lee K.J. 2003. Essential Otolaryngology. McGraw-Hill.
Jones A.W. et al.1998. Diseases of
the Head & Neck, Nose and Throat.
Oxford University Press