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Differential List NEURO OTOLOGY FACIAL NERVE PALSY 1. 2. 3. 4. 5. 6. Bells Palsy 50% Trauma 25% Zoster 12% Infection 5% (AOM, CSOM, cholesteatoma, malignant otitis, BOSO) Tumour 5% (schwannoma, haemangioma) Other 3% A: autoimmune B: BIH, bone dysplasia eg osteopetrosis or fibrous dysplasia C: congenital (mobius, goldenhars) D: diabetic neuropathy E: dEmyelination F: funny infections eg lyme disease, leprosy G: granulomatous (sarcoid), BILATERAL FACIAL NERVE PALSY 1. Congenital (mobius) 2. Acquired a. Bells b. Traumatic (base of skull, brainstem) c. Guillain Barre d. Rare (sarcoid, leukemia, osteopetrosis) e. CENTRAL Clot eg embolism/infarction E dEmyelination Nutritional Tumour Retrocochlear lesion Alcohol Lesion of Posterior cranial fossa CONGENTAL FACIAL N PALSY 1. congenital a. mononeuritis agenesis b. syndromal i. Mobius ii. Hemifacial microsomia c. Teratogen, rubella, thalidomide 2. early acquired a. birth trauma b. bells c. infectious i. EBV ii. Meningitis iii. Poliomyelitis iv. AOM CEREBELLOPONTINE ANGLE Primary tumours of the CP angle (%) - Gonzales 1) 2) 3) 4) 5) 75% 6% 6% 5% 6% Acoustic Schwannoma Meningioma Epidermoid Cranial nerve Schwannoma Petrous Apex infilt CPA Benign 1. 2. 3. 4. 5. Arachnoid cyst Aneurysm Asymmetrical pneumatisation Chondroma A rare benign neoplasm eg paraganglioma, adenoma, haemangioma Malignant 1. 2. 3. 4. 5. SCC Chondrosarcoma Adenocarcinoma MSG Metastases (KOTLPTB) Intraaxial tumours 1. haemangioblastoma 2. medulloblastoma 3. astrocytoma 4. glioma – brainstem 5. ependymoma Points to mention about Radiology for CPA angle A: B: C: D: F: G: Asymmetry or symmetry with IAC, Acute or obtuse angle with tumour/petrous face Bone changes - widening of IAC (AS) or hyperostosis (meningioma) Calcification with Meningioma Dural tail Fluid density (epidermoid or Arachnoid cyst) – look for CSF cap for VIII Gadolinium enhancement CLIVUS AREA 1. 2. 3. 4. 5. Pituitary Macroadenoma Clival Chordoma Chondrosarcoma Meningioma Sphenoid Malignancy PETROUS APEX Cystic 1. cholesterol granuloma 2. cholesteatoma 3. mucocoele a. exclude – bone marrow, abnormal pneumatization b. other ddx = petrous carotid aneurysm, petrous apex encephalocoele Solid 1. chondroma 2. chondrosarcoma 3. giant cell tumour 4. haemangioma 5. metastatic tumour 6. lymphoma, myeloma, plasmacytoma 7. meningioma 8. trigeminal schwannoma PARAPHARYNGEAL SPACE MASS 1. 2. 3. 4. Salivary gland tissue Neurogenic (shwannomata, neurofibroma) Paraganglioma (CBT>GJ>GV) Other (adult = SCC, NPC, child = RMS, lymphoma) - 50% 25% 15% 10% DESTRUCTIVE BASE OF SKULL 1. 2. 3. 4. 5. 6. Metastases Osteomyelitis Paraganglioma Plasmacytoma Eosinophilic granuloma (histiocytosis X) Leukaemic deposits JUGULAR FORAMEN 1. 2. 3. 4. 5. 6. Paraganglioma GJ>GV>GT Shwannoma Chordoma Chondroma Chondrosarcoma Metastases (KOTLPTB) HYPEROSTOTIC BONE 1. chronic osteomyelitis 2. bone dysplasia a. pagets disease b. osteopetrosis 3. meningioma 4. osteoblastic metastases ULCER IN EAC 1. 2. 3. 4. 5. Malignancy (SCC, adenoid cystic, BCC, MSG, Lymphoma) Malignant otitis externa Osteoradionecrosis of temporal bone External canal cholesteatoma Other a. First arch anomaly b. Dermatologic disorders c. Trauma - burns, chemical d. Viral, fungal inflammation MASS in EAC 1. Neoplastic a. Malignant (SCC, MSG) b. Benign (exostoses, osteoma, ceruminoma) 2. Cholesteatoma 3. Temporal bone # st 4. 1 branchial arch abnormality EAC TUMOUR benign 1. osteoma / exostoses 2. adenoma 3. papilloma 4. ceruminoma 5. pleomorphic adenoma 6. chondroma 7. haemangioma malignant 1. SCC 2. BCC 3. Melanoma 4. adenocarcinoma 5. malignant ceruminoma 6. mucoepidermoid / adenoid cystic 7. other paediatric 1. rhabdomyosarcoma 2. neuroblastoma 3. histiocytosis X CANAL STENOSIS 1. 2. 3. 4. 5. 6. 7. Congenital (atresia) Infective Inflammatory (cicatrizing otitis externa) Neoplastic (eosinophilic granuloma) X-rays eg Radiotherapy Post surgical eg blind sac Trauma RED MASS IN ME 1. 2. 3. 4. Neoplasm a. glomus b. adenoma c. meningioma d. minor salivary gland neoplasm e. schwannoma f. histiocytosis g. plasmacytoma Normal variant a. high jugular bulb b. ectopic ICA / persistent stapedial artery Inflammatory a. schwartz’s sign – otosclerosis b. cholesterol granuloma c. fibrous dysplasia Trauma a. haemotympanum WHITE MASS IN MIDDLE EAR 1. 2. 3. 4. 5. Cholesteatoma Tympanosclerosis Endostosis Graft/prosthesis Tumour a. Schwannoma b. Osteoma c. other PINNA INFLAMMATION 1. 2. Infective: a. Bacterial b. Viral – HZO Inflammatory: a. Allergy - HA/ topical meds b. Relapsing polychondritis c. SLE d. Dermatologic disorders MIDDLE EAR EFFUSION 1. 2. 3. 4. Infective a. B, V Traumatic a. Barotraumas Inflammatory – a. wegner's b. sarcoid Neoplasia TM Perforation 1. 2. 3. 4. CSOM a. Cholesteatoma Iatrogenic Trauma Inflammation - TB, Syphilis, Wegner's AURAL POLYP 1. 2. 3. 4. 5. Neoplasia Sentinel polyp – cholesteatoma Skull Base Osteomyelitis CSOM Others: a. 1st arch abnormalities b. Traumatic c. Inflammatory - wegners, TB etc MENIERE’S DISEASE Central 1. acoustic neuroma 2. glioma 3. meningioma 4. Arnold chiari 5. MS 6. CVA / TIA 7. aneurysm Peripheral 1. BPPV 2. viral labrynthitis 3. perilymph fistula 4. trauma 5. autoimmune ear disease 6. migrainous vertigo Metabolic 1. diabetes 2. hyperthyroidism 3. neurosyphillis 4. cogan’s RHINOLOGY UNILATERAL PROPTOSIS ADULT 1. 2. 3. 4. 5. Inflammatory (graves disease – usually bilateral but still most common) Infective (complication sinusitis, orbital apex syndrome, mucocele, granulomatous) Neoplastic (extra orbital and intraorbital) Pseudotumour (non-granulomatous local inflammation of unknown cause) Trauma CHILD 1. Inflammatory 2. Congenital (dermoid, vascular anomaly) 3. Neoplastic (rhabdomyosarcoma, lymphoma, neuroblastoma, leukaemia) PTOSIS 1. congenital 2. IIIrd Nerve palsy 3. Horner’s Syndrome 4. Myasthenia gravis 5. Myopathy 6. pseudoptosis – eyelid oedema UNILATERAL SINUS OPACITY 1. 2. 3. 4. 5. 6. Infective (unilateral sinusitis) Mycetoma Antrochoanal polyp Inverted papilloma inflammatory – wegeners, sarcoid, churg-strauss) Neoplasia MIDLINE NASAL MASS IN CHILD 1. 2. 3. 4. 5. 6. Dermoid, teratoma encephalocele Glioma Adenoid Thornwalt’s Neoplastic (JNA, rhabdomyosarcoma, lymphoma or leukaemia) MIDLINE DESTRUCTION 1. 2. 3. 4. 5. 6. 7. 8. lymphoma wegener’s mucormycosis cocaine malignancy syphilis TB churg-strauss NASAL MASS IN CHILD 1. 2. 3. 4. encephalocele dermoid, teratoma glioma nasolacrimal duct cyst, nasopalatine duct cyst NASAL VESTIBULE LESION 1. Infective (B – Staph vestibulitis, V – HSV, F/P – ringworm) 2. Inflammatory (sarcoid, wegeners) 3. Neoplastic a. (include squamous papilloma – most common, SCC, BCC, Melanoma, Sarcoma, Lymphoma) SEPTAL PERFORATION / SADDLING 1. 2. 3. 4. 5. Infective (TB, syphilis, invasive fungal, rhinoscleroma, leprosy) Inflammatory (sarcoid, wegeners, relapsing PC, Churg-Strauss, SLE) Neoplastic (lymphoma, melanoma, SCC) Pharmacologic (rhinitis medicomentosa, cocaine) Trauma (iatrogenic, digital) NASAL MASS MEDIAL TO MIDDLE TURBINATE 1. 2. 3. 4. 5. SCC MSG (adenocarcinoma, mucoepidermoid, adenoid cystic, acinic cell) esthesioneuroblastoma Mucosal melanoma SNUC RHINOSINUSITIS 1. Allergic (50%) 2. Non-Allergic (50%) a. Infective include anatomical factors and physiological factors b. Hormonal (menstruation, menopause, pregnancy, puberty) c. Atrophic (primary Vs secondary) d. Traumatic (thermal, chemical, physical) e. Endocrine (thyroid disease) f. Drugs (medicomentosa, cocaine, OCP, antihypertensives, NSAID) g. Choanal atresia (abnormal airflow) h. Vasomotor NASAL MASS IN CHILD 1. 2. 3. 4. 5. 6. 7. 8. 9. Dermoid (midline, frontotemporal, parietal, orbital, nasoglabellar) encephalocele glioma Dacrocystocele (nasolacrimal duct cyst) Tornwalt’s cyst Rathke’s pouch cyst angiofibroma Lymphoma Rhabdomyosarcoma FIBROOSSEOUS LESIONS of Paranasal sinuses • • Of the nonepithelial tumors that involve the sinonasal cavities, o 25% are osseous or fibroosseous lesions. Grouped o abnormal bone development causing masses eg Paget’s disease, fibrous dysplasia, cemento-ossifying dysplasia, cherubism, giant cell reparative granuloma o benign osseous tumors eg osteoma, osteochondroma, exostosis, osteoid osteoma, osteoblastoma, ossifying fibroma, chondroma, giant cell tumor o malignant tumors eg chondrosarcoma, osteogenic sarcoma VAULT NOSE MASS 1. 2. 3. 4. 5. 6. 7. SCC Adenocarcinoma Esthesioneuroblastoma Melanoma minor salivary gland neoplasm SNUC Lymphoma FACIAL LESION 1. SCC 2. BCC 3. Melanoma 4. Merkel cell Sarcoma 5. Karposi Sarcoma 6. Lymphoma 7. Others: 8. Benign - KA, Actinic keratosis, Seborrheic keratosis, Bowen's disease 9. Inflammatory - B, V, F inc TB 10. Traumatic ATROPHIC RHINITIS 1. Secondary a. Postop b. post inflammatory c. Underlying inflammation (sarcoid, WG) or neoplasia 2. Primary - Kebsiella Ozena VPI 1. congenital 1. Idiopathic insufficiency of the musculature 2. Congenital palatal insufficiency - cleft palate, short palate, pharynx too capacious (palatopharyngeal disproportion) 3. Submucous cleft palate or “occult submucous cleft palate” - absence of musculus uvulae on nasal surface on nasopharyngoscopy 2. post-op 1. Following cleft palate repair - incidence of VPI = 15%-30% 2. After mid-face advancement (Le Fort I or bimaxillary osteotomy) 3. After adenoidectomy 3. enlarged tonsils restrict airway t/f open sphincter 4. neurogenic 1. hemifacial microsomia w unilateral weakness, 2. peripheral neuritis, 3. myasthenia gravis, 4. nuclear lesions, 5. bulbar poliomyelitis, supranuclear paresis (usually congenital & typified by cerebral palsy) 6. upper & lower motor neuron lesions 7. Functional hypernasality in deaf patients. 8. Hysterical hypernasality HEAD AND NECK PAROTID LUMP 1. Infective a. (TBATS) (toxo, bartonella (cat-scratch), actinomycoses, TB, syphilis) b. Viral – paramyxovirus, EBV CMV c. Sialoadenitis 2. Inflammatory a. Wegeners b. Sarcoid c. Necrotising sialometaplasia d. Benign lymphoepithelial lesion (HIV, Sjogrens, Miculicz, punctuate parotitis) 3. Neoplastic a. Benign i. Pleomorphic ii. Monomorphic 1. Warthins 2. Oncocytoma iii. Papilloma 1. inverted 2. intraductal iv. haemangioma v. neurofibroma vi. lipoma b. malignant i. mucoepidermoid ii. acinic cell iii. adenoid cystic iv. carcinoma ex pleomorphic v. lymphoma (MALT) vi. basal cell adenocarcinoma vii. epithelial – myoepithelial ca viii. sebaceous carcinoma ix. adenocarcinoma x. myoepithelial malignancy xi. small cell carcinoma xii. malignant oncocytoma c. Metastatic i. SCC ii. Melanoma iii. Renal cell ca iv. Thyroid ca MIDLINE NECK MASS 1. 2. 3. 4. 5. 6. dermoid, epidermoid, teratoma thyroglossal duct cyst thyroid nodule thyroid malignancy delphian node (draining aerodigestive malignancy) direct extension of upper aerodigestive malignancy PULSATILE NECK MASS 1. 2. 3. 4. ectatic carotid aneurysm paraganglioma transmitted pulsation LATERAL NECK MASS 1. Lymph node a. Reactive lymph node b. Suppurative lymph node c. Granulomatous disease of head and neck d. Metastatic disease in lymph node from upper aerodigestive tract or skin e. Primary malignancy of lymph node eg lymphoma or leukaemia 2. 3. 4. 5. 6. Branchial anomaly (cyst, sinus, fistula) Lipoma, Fibroma, Vascular anomaly Schwannoma Paraganglioma (glomus vagale, carotid body tumour) Direct extension of upper aerodigestive tumour CALCIFICATION IN LYMPH NODE 1. Neoplastic – (SCC, Papillary Ca thyroid, ~medullary thyoird Ca) 2. Infective (TB) 3. Dystrophic calcification CYSTIC NECK MASS benign 1. 2. 3. 4. 5. 6. 7. 8. thyroglossal duct cyst ranula sebaceous cyst dermoid, teratoma branchial anomaly lymphatic malformation / vascular malformation cystic thyroid nodule lipoma malignant 1. cystic metastatic lymph node (usually waldeyers ring SCC) 2. papillary Ca Thyroid 3. branchiogenic carcinoma SUBMANDIBULAR MASS 1. 2. 3. 4. 5. Infective (sialadenitis) Inflammatory Neoplastic (primary salivary gland or Lymph node) sialadenosis plunging ranula SKIN 1. 2. 3. 4. BCC (rodent ulcer) SCC Neuroendocrine (cutaneous melanoma, merckel cell carcinoma skin metastases (rare) MOUTH ULCER 1. infective a. bacterial i. vincent’s, TB, syphilis b. viral i. HSV,CMV,HIV,Coxsackie c. Fungal i. Erosive candida 2. inflammatory ( a. aphthous ulcer –inflammatory bowel b. pemphigus, pemphigoid, c. autoimmune i. lichen planus d. bechet’s e. reiter’s f. necrotizing sialometaplasia 3. neoplastic (SCC, variant SCC, MSG) 4. xerostomia 5. pharmacologic a. aspirin, b. erythema multiforme, c. steven - johnson 6. trauma a. chemical b. physical c. radiation 7. anaemia a. B12 / folate deficiency MOUTH LESION (BLUE) 1. 2. 3. 4. ranula vascular anomaly jaw cyst neoplastic MOUTH LESION (WHITE) 1. 2. 3. 4. Leukoplakia Lichen Planus Candidiasis Chemical burn (eg aspirin) MOUTH LESION (BROWN) 1. 2. 3. 4. 5. Melanosis (racial, smoking, addison’s, Puetz Jegher) Melanoma Amalgam tattoo Black hairy tongue Kaposi’s sarcoma MOUTH LESION (RED) 1. 2. 3. 4. erythroplakia candidiasis lichen planus vascular anomaly XEROSTOMIA 1. 2. 3. 4. 5. 6. radiotherapy drugs a. anticholinergics / phenothiazides b. chemotherapy / antiparkinsons surgery – salivary glands sjogren’s syndrome sarcoidosis lymphoma JAW LESION 1. Non Odontogenic a. Nasoplatine (midline) b. Nasolabial 2. True Odontogenic a. Inflammatory (radicular, paradental) b. Developmental (follicular, OKC, periodontal, glandular) c. Neoplastic (ameloblastoma, ameloblastic Ca) 3. Infiltration from other area eg (Oral cavity, Salivary gland) 4. Metastases (KOTLPTB) ANGLE OF JAW MASS 1. Parotid lump 2. Lymph node mass a. Neoplasia b. Inflammatory 3. Parapharyngeal mass 4. Aneurysm 5. Lipoma 6. Jaw / teeth – cyst tumour 7. Mesenchymal tumour LARYNX / HYPOPHARYNX – MASS Congenital 1. saccular cyst 2. cystic hygroma 3. epidermoid Inflammatory 1. pyogenic granuloma 2. epiglottitis 3. laryngopyocoele 4. ductal retention cyst Granulomatous 1. wegeners 2. amyloidosis 3. sarcoidosis 4. TB 5. syphilis Neoplastic – benign 1. papilloma 2. adenoma 3. oncocytoma 4. granular cell tumour 5. chondroma 6. rhabdomyoma 7. haemangioma 8. neurolemmomma 9. leiomyoma 10. lipoma 11. paraganglioma 12. lymphangioma Neoplastic – malignant 1. SCC 2. verrucous SCC 3. chondrosarcoma 4. adenoid cystic 5. mucoepidermoid 6. neuroendocrine a. merkel cell b. carcinoid c. atypical carcinoid d. small cell 7. melanoma 8. synovial sarcoma 9. malignant schwannoma 10. liposarcoma 11. rhabdomyosarcoma 12. karposi’s sarcoma 13. lymphoma a. HL b. NHL 14. Metastases SUPRACLAVICULAR MASS 1. metastatic nodal mass a. GIT b. Breast c. Chest d. Locoregional 2. primary nodal malignancy – lymphoma 3. cystic hygroma 4. lipoma 5. meurilemoma 6. angioma 7. anurysm of surpraclavicular vessels LATERAL NECK MASS - POSTERIOR TRIANGLE 1. Congenital a. Vascular malformation / haemangioma b. Dermoid / teratoma 2. Acquired a. Inflammatory – LN b. Neoplastic – B or M c. Vascular LATERAL NECK MASS - ANTERIOR TRIANGLE 1. 2. 3. 4. Neoplastic – LN or salivary Inflammatory – LN or SG Branchial cyst Carotid body / neural tumour GINGIVAL ENLARGEMENT 1. Leukaemia 2. Hormonal – pregnancy, puberty 3. Medications – phenytoin, cyclosporine MACROGLOSSIA 1. Primary a. Down syndrome, or developmental eg Beckwith Wiedemann, Hurlers, cretinism 2. Tumors a. Hemangioma, lymphangioma, neurofibroma, neurilemmoma, or thyroglossal duct cyst 3. Infections a. Actinomycosis, tuberculosis, histoplasmosis, or syphilis 4. Metabolic – a. Hypothyroidism, acromegaly, multiple myeloma, or amyloidosis 5. Other a. Amyloid, b. Angioedema, c. sarcoidosis, d. superior vena cava syndrome ORAL NEUROFIBROMATA 1. NF1 2. NF2 3. Tuberous sclerosis PALATE ULCER 1. 2. 3. 4. 5. SCC MSG tumour Lymphoma Necrotising sialometaplasia Others: a. Neoplastic b. Inflammatory - TB, sarcoid, Wegners c. Traumatic - denture granuloma PALATE LUMP 1. 2. 3. 4. 5. Congenital - alveolar, developmental cyst Neoplastic B or M Inflammatory - wegner's, sarcoid, NecrotisingSM, mucocele Infective - TB, Rhinoscleroma Traumatic - denture granuloma LARYNGOLOGY UNILATERAL VOCAL CORD IMMOBILITY Cricoarytenoid fixation 1. trauma haemarthrosis 2. local inflammation (infection or FB) 3. arthritis RLN palsy 1. Neoplastic a. Ca Larynx (RLN palsy or cricoarytenoid invasion or significant tumor bulk) b. Ca Lung c. Mediastinal Pathology d. Skull base, central 2. Trauma a. Iatrogenic – a. thyroid, carotid endartectomy, anterior cervical fusion b. intubation b. blunt, penetrating trauama 3. Neuritis a. Toxic (ETOH, lead, arsenic) b. Diabetic neuropathy c. Ischaemic (collagen vascular disaease) 4. Infective a. Viral b. TB 5. Central – bulbar palsy, ALS 6. Idiopathic (20%) BILATERAL VOCAL CORD IMMOBILITY 1. thyroid surgery (almost all cases) 2. intubation trauma (posterior glottic stenosis) 3. inflammatory arthritis 4. neuromuscular weakness a. myasthenia gravis b. muscular dystrophy c. multiple sclerosis d. Arnold chiari / hydrocephalus VOCAL CORD PALSY (CHILDREN) 1. Neurological disease –benign congenital hypotonia, cerebral palsy, leukodystrophy, Charcot –Marie – Tooth disease 2. Meningomyelocele with Arnold-Chiari malformation and hydrocephalus 3. Birth trauma 4. Surgical trauma – TOF repair, Cardiac surgery, Intubation injury to RLN 5. Malignancy 6. Idiopathic SUBGLOTTIC STENOSIS 1. Congenital (5%) 2. traumatic – aquired stenosis (prolonged ETT), granuloma 3. inflammatory – 4. infectious – croup, TB, Syphilis, klebsiella rhinoscleroma 5. Autoimmune – Wegener’s, sarcoid, relapsing polychondrittis 6. Other - GORD 7. neoplastic – Haemangioma, papilloma, SCC 8. Idiopathic STRIDOR (CHILDREN) 1. 2. 3. 4. 5. 6. Laryngomalacia 70% Subglottic Stenosis / Webs Vocal cord palsy Tracheomalacia Subglottic haemangioma Others – clefts, cysts etc VOCAL CORD LESION Specific lesions 1. Nodules 2. Polyp 3. Cyst a. Ductal retention b. Squamous inclussional (epidermoid) 4. Granuloma 5. Reinkes oedema Inflammatory 1. amyloidosis 2. wegener’s 3. TB 4. leprosy 5. sarcoid 6. histoplasmosis Dysplasia 1. mild 2. moderate 3. severe 4. CIS Tumour Benign 1. papilloma 2. pyogenic granuloma Malignant See Ddx mass in larynx CYSTIC LARYNGEAL LESION 1. 2. 3. 4. anterior saccular cyst (small ant, mucous filled) lateral saccular cyst / laryngocoele cystic hygroma (endodermal anomaly of lymphatic vessels) intracordal cyst a. ductal retention cyst i. rupture → sulcus b. epidermoid OPERATIVE CASES RETROBULBAR BLEED 1. 2. 3. 4. 5. caused by retraction of significant vessel, usually anterior ethmoid if on table assessment by orbital balottment only way if in recovery visual acuity and balottment (most sensitive = light/dark sat + red colour) immediate lateral canthotomy and cantholysis simultaneous administration of steroids (8mg dexamethasone) and mannitol (10%-20% infusion) reassessment of orbital pressure via balottment external anterior ethmoid artery ligation 1. injection + tarsorrhaphy 2. lynch incision (midway between nasal midline and lacrimal puncta) 3. down to periosteum 4. periosteum lifted off lacrimal and ethmoid bone 5. fronto-ethmoidal suture encountered and followed (24mm, 12mm, 6mm) 6. using malleable brain retractor gently retract orbital periosteum 7. clip or bipolar vessels if still significant orbital pressure - medial wall decompression (diploplia 20%) 6. 7. 8. FACIAL NERVE PALSY POST EAR SURGERY 1. 2. 3. 4. 5. 6. 7. wait for local anaesthetic to wear off protect eye loosen bandage administer IV steroids remove dressing from ear IF NO improvement get senior otologist involved I would expect the senior otologist will take the patient for exploration within 72 hours) INTRA-OP FACIAL NERVE INJURY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. cease drilling inform anaesthetist optimize conditions eg hemostasis with speed ball, decrease BP etc visualize defect use methylene blue (taken up by connective tissue) contact senior otologist and ask for intraop assisstance decompress proximal and distal to injury steroids if safe close and refer to senior otologist discuss with patient and family I would expect senior otologist will explore within 48 hours less than 33% no further treatment 33%-50% controversial >50% complete transaction and reconstruct with GA or Sural nerve graft best outcome HB III FACIAL NERVE PALSY AFTER EAR SURGERY 1. 2. 3. 4. local anaesthetic nd direct trauma 2 genu or tympanic segment retrograde trauma after injury to chorda tympani reactivation of herpes simplex or zoster with bells phenomenon LASER FIRE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. STOP laser inform anaesthetist cease ventilation and disconnect circuit extubate and place ETT in bucket of water douse airway with 5 mls of saline reintubate with fresh ETT laryngoscopy/bronchoscopy to assess damage assess face and oropharynx +/- low tracheostomy if severe burns root cause analysis RECALCITRANT EPISTAXIS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. appropriate assessment with history and exam LOCAL = examine nose and appropriate preparation REGIONAL = manage blood pressure SYSTEMIC = take blood, check for coagulopathy and G+ H pack nose (merocel/rapid rhino pack) formal pack using foleys catheter or epistat balloon and guaze indication for OT greater palatine block ipsilateral sphenopalatine contralateral sphenopalatine external clipping of anterior ethmoidal interventional radiology with embolisation ipsilateral IMAX, FACIAL repeat embolisation with contralateral IMAX and FACIAL if continues despite this and appropriate pack external carotid artery ligation above superior thyroid BLEEDING ADENOID • • • • • • Post adenoidectomy Bleeding in recovery Simple measures o Lie on side o Drixine down nose o Bloods Hb Coags G and H o Cant attempt foleys catheter as temporizing measure or as treatment and remove next day by slowly deflating ml by ml Take back to OT Full stomach o Will need rapid sequence induction with cricoid pressure Have available o Tonsil/adenoid tray o With drixine on swab o Suction x 2 Light sources Laryngoscopes Bronchoscopes In case anaesthetist cant get airway because of blood Place tonsil gag then place drixine/adrenalin soaked swab in nasopharynx suck out blood Wait Feel for remaining adenoid tissue o Recurrette any remaining adenoid tissue Look o Direct vision nasoendoscope o Mirror Suction diathermy to bleeders o Replace pack o Wait If still bleeding o Check for any obvious bleeders if cant stop o Formal pack o Rolled gauze suture 3 threads one out each nostril and tied on thru mouth o Leave intubated o Check coags o Remove pack next day in OT o o o • • • • • • FOREIGN BODY IN PAEDIATRIC AIRWAY • Take to OT o Tell want senior anaesthetist • • • • Discuss anaesthetic with anaesthetist Gaseous induction with sevoflurane No positive pressure Have available o 2 light source o A range of slotted laryngoscopes o Range of bronchoscopes o Range of peanut removing forceps o Optical guided forceps • IV access after induction • • • • • • • • • • • • • • Slotted laryngoscope visualize airway Connect or and gases to laryngoscope Topical anaesthetic to airway and down trachea Rigid telescope down scope look at airway Look good side first Look at foreign body Place bronchoscope remove laryngoscope Change gases tube Wait till stable Suction out secretions Place adrenalin/drixine on any friable granulaton tissue Carefully remove with bronchoscope Do not take into bronchoscope will shear off Rotated so that long axis of FP is in the line of the cords to avoid damage Scenario • If drop • Go in and retrieve if cannot • push down to right main bronchus again • Wait till numbers stabilize then re attempt removal Scenario • Drop down left main bronchus • Granulation down right main bronchus • Starting to desaturate • Bring bronchoscope to back above carina • This is the only time you can use positive pressure • When sats stable • Remove Scenario • Attempted removal lots of bleeding • Place adrenalin or drixine down • Wait • Reattempt • Removal if cannot remove • Abort procedure • Antibiotics and steroids • Reattempt in 24 hours • If unsuccessful second attempt get cardiothoracic input • • After removal recheck for any further FBs Place some drixine on granulation tissue CAUSTIC INJURIES Child Immediate LBO indicated if: - airway compromise - drooling - liquid agent ingested Otherwise, LBO indicated at 24 hours to assess extent of damage, if mucosal injury is evident beyond posterior tongue Flexible Gastroscopy only indicated if: - liquid agent ingested (possible gastric outlet injury) Ba swallow + meal at 3 weeks – for stricture FB / Caustic Injuries Partial Thickness Oesophageal Injuries NGT passed via oesophagoscope NBM iv antibiotics Consider contrast swallow at 1 day Full Thickness Oesophageal Injuries in: Neck = NGT passed via oesophagoscope NBM iv antibiotics Contrast swallow at 1 week Thoracic = NGT passed via oesophagoscope NBM iv antibiotics immediate Cardiothoracic consult (? patch repair with bowel or pericardium to prevent mediastinitis) Abdominal = NGT passed via oesophagoscope NBM iv antibiotics immediate Upper GIT Surgery consult (? laparatomy to prevent peritonitis) NECK DISSECTION INCISIONS 1. Modified Apron 2. Hockey stick 3. Inverted Hockey stick - selective neck levels II-V levels I-V RADICAL NECK 1. Use inverted hockey stick with horizontal limb from submental to mastoid tip parallel to mandible – with descending limb from posterior over lateral portion of posterior triangle 2. commence with level I EXTERNAL-INTERNAL CAROTID ANASTOMOSIS 1. 2. 3. 4. orbit (supraorbital-STA, lacrimal-meningeal) nose (anterior ethmoid-sphenopalatine-superior labial-ascend GP) middle ear (tympanic plexus – caroticotympanic-inferior/superior tympanic) dura