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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5248_Библиотеки_им_академика_М_И_Перельмана.pdf
6 Emergencies
175
Fig. 6.4 Little’s area (Kiesselbach’s plexus) with its arterial supply. Illustrated by Vikum
Liyanaarachchi
3. What is the signicance of the sphenopalatine artery in epistaxis
management?
The sphenopalatine artery is a major blood supply to the nasal cavity and is
often the source of posterior epistaxis. Ligation or cauterization of the SPA can
effectively control bleeding in cases where conservative measures have failed.
4. How can you differentiate between anterior and posterior epistaxis?
Anterior epistaxis typically presents with blood owing from the nostril(s),
while posterior epistaxis can present with blood owing into the oropharynx,
causing the patient to swallow blood and potentially leading to nausea, vomiting,
or aspiration.
5. What are the conservative measures typically employed before resorting to
surgical intervention for epistaxis?
Conservative measures for epistaxis control include nasal compression, appli-
cation of topical vasoconstrictors or decongestants, chemical cautery (e.g. silver
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S. Mallick et al.
nitrate), and anterior or posterior nasal packing. These measures are often
attempted before resorting to surgical intervention.
6. What other surgical options are available for epistaxis control if SPA liga-
tion is not successful or not feasible?
Other surgical options for epistaxis control include endoscopic cauterization
of bleeding vessels, anterior and posterior ethmoidal artery ligation, and, in rare
cases, external carotid artery ligation or embolization. Historically, a Young’s
procedure was also considered. The choice of surgical intervention depends on
the location of bleeding, the underlying cause, and the surgeon’s experience and
preference.
7. How could you manage anterior ethmoid artery bleeding?
If severe arterial anterior bleeding (e.g. immediately after FESS), one could
expect anterior ethmoidal artery bleeding. Usually, the artery retracts, and it
becomes very difcult to control the bleeding endoscopically due to blood
obscuring the surgical eld.
Lynch-Howarth incision down to bone:
• Elevate the periosteum, and identify the lacrimal sac.
• Anterior ethmoidal artery is 24mm posterior to the anterior lacrimal crest, in
the line of the fronto-ethmoidal suture. The posterior ethmoidal artery lies
12mm behind this, and the optic nerve is 6mm behind this. These distances
are variable.
• Diathermy and/or artery clipping could be used to control bleeding.
8. What common absorbable materials could be used to control bleeding?
• Floseal: bovine gelatine with human lyophilized human thrombin
• Surgio: porcine gelatin with human thrombin
• Kaltostat: alginate
• Surgicel: cellulose
• Tisseel as brin glue: human plasma cryoprecipitate
6.4 Foreign Body Removal (Ear, Nose, Throat)
Indications for Surgery
• Presence of a foreign body in the ear, nose, or throat.
• Failure of conservative measures to remove the foreign body.
• Risk of complications or injury due to the foreign body.
Specific Risks Involved with the Surgery
• Injury to surrounding structures
• Infection
• Bleeding
• Retention or migration of the foreign body
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177
• Aspiration (for foreign bodies in the throat)
• Anaesthesia complications (for rigid oesophagoscopy)
Steps of the Surgery
• Preparation: Administer appropriate anaesthesia (local or general, depending on
the location of the foreign body and the patient’s condition).
Ear foreign body removal techniques:
• Irrigation: Use a syringe to gently ush the ear canal with warm water, attempting to oat the foreign body out.
• Suction: Apply gentle suction using a small catheter to remove the foreign body
from the ear canal.
• Forceps: Carefully grasp the foreign body with forceps or crocodile forceps, and
gently remove it, as seen in Fig.6.5.
• Loop or hook: Use a small loop or hook to dislodge and remove the foreign body,
as seen in Fig.6.6.
Nose foreign body removal techniques:
• Parent’s kiss: Have the parent or caregiver close the child’s mouth and deliver a
short, forceful puff of air into the child’s mouth, which can propel the foreign
body out of the nostril.
• Positive pressure: Have the patient occlude the unaffected nostril and exhale
forcefully through the affected nostril.
• Forceps or suction: Use forceps, a suction catheter, or a specialized foreign body
removal instrument to gently extract the foreign body.
Fig. 6.5 Foreign body
being removed from ear
canal with crocodile
forceps. Illustrated by
Vikum Liyanaarachchi
178
Fig. 6.6 Foreign body
being removed from ear
canal with wax hook.
Illustrated by Vikum
Liyanaarachchi
S. Mallick et al.
Throat foreign body removal techniques:
• Rigid oesophagoscopy: Use a rigid oesophagoscope to visualize the foreign
body and extract it using forceps or other specialized instruments.
• Flexible endoscopy: In some cases, a exible endoscope can be used to visualize
and remove the foreign body.
• Surgical intervention: In rare cases, a surgical intervention may be required to
remove an impacted or hazardous foreign body in the throat.
Tracheal foreign bodies:
• Use a ventilating bronchoscope which has an ability to visualize, grasp, suction,
and ventilate the patient, as seen in Fig.6.7.
Important Points to Note During the Surgery
• Adequate visualization and atraumatic techniques are essential to minimize the
risk of complications.
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Fig. 6.7 Ventilating bronchoscope. Illustrated by Vikum Liyanaarachchi
• Be prepared to manage potential complications, such as bleeding or airway
obstruction.
• Monitor the patient closely for any signs of complications or retained foreign
body fragments.
Questions a Consultant Might Ask a Trainee About the Operation
1. When should you avoid using irrigation to remove an ear foreign body?
Irrigation should be avoided if the foreign body is organic (e.g. seeds, insects),
as water can cause the foreign body to swell or become more difcult to remove.
It should also be avoided if there is a known or suspected tympanic membrane
perforation.
2. What are the potential complications of using forceps or other instruments
to remove a nasal foreign body?
Potential complications include injury to the nasal mucosa, bleeding, or accidental pushing of the foreign body further into the nasal cavity.
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S. Mallick et al.
3. Why is rigid oesophagoscopy preferred over exible endoscopy for throat
foreign body removal in some cases?
Rigid oesophagoscopy allows for better visualization, more precise control,
and use of specialized instruments for foreign body removal. It may be preferred
in cases where the foreign body is large, sharp, or impacted.
4. In which situations is surgical intervention necessary for throat foreign
body removal?
Surgical intervention may be required for foreign bodies that cannot be safely
removed using endoscopic techniques and are causing severe symptoms or complications (e.g. airway obstruction, perforation) or if the foreign body has
migrated to an inaccessible location.
5. How can you minimize the risk of aspiration during foreign body removal
from the throat?
To minimize the risk of aspiration, ensure proper patient positioning, use
adequate anaesthesia, maintain airway patency, and use atraumatic techniques
during foreign body removal. Be prepared to manage airway complications if
they arise and consider consultation with an anaesthesiologist or intensivist for
complex cases or high-risk patients.
6. Is it safe to wait for the next day in cases of foreign body inhalation?
Yes, if the foreign body has been identied and is not considered high risk
such as a button battery or if the object is sharp. If the child is distressed however, then you may consider removing it sooner. It is important to recognise that
this is an emergency and where possible it should be removed as soon as possible.
7. What are the types of bronchoscopy?
• Flexible bre-optic bronchoscopy.
• Rigid:
– Ventilating bronchoscope as seen in Fig.6.7.
– Venturi: The Venturi bronchoscopes are essentially open-ended metal
tubes. Gas exchange is brought about by jet insufation of the lungs with
oxygen and entrained air using a Sanders injection. This technique is only
used in patients >40kg due to high risk of barotrauma.
8. How can you identify the size of the bronchoscope?
In general, it is half a degree below age-appropriate ETT (ID). The correct size
is the one that allows an audible leak at 20cm H
O pressure. One can also nd the
2
correct size (age dependant) on the appropriate chart mounted on the theatre.
6.5 Drainage ofDeep Neck Infections (Peritonsillar,
Parapharyngeal, Retropharyngeal Abscesses)
Indications for Surgery
• Clinical or radiological evidence of a deep neck abscess (peritonsillar, parapha-
ryngeal, retropharyngeal)
• Failure of conservative management, such as antibiotics and observation
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181
• Compromised airway or risk of airway compromise
• Evidence of sepsis or systemic infection
Specific Risks Involved with the Surgery
• Injury to adjacent structures (e.g. nerves, blood vessels, salivary glands)
• Incomplete drainage or recurrence of the abscess
• Aspiration
• Bleeding
• Infection
• Anaesthesia complications
Steps of the Surgery
1. Preparation: Administer appropriate anaesthesia (local or general, depending on
the location of the abscess and the patient’s condition), secure the airway, and
position the patient.
Peritonsillar abscess drainage:
1. Identify the point of maximum uctuance, typically above the superior pole of
the tonsil.
2. Inltrate the area with local anaesthesia and a vasoconstrictor.
3. Make a small incision at the point of maximum uctuance, and use a blunt
instrument to open up and break up loculations (Hilton method) allowing for pus
drainage.
4. Gently express pus from the abscess cavity and irrigate with saline.
Parapharyngeal abscess drainage:
1. Perform a transcervical approach, making an incision along the anterior border
of the sternocleidomastoid muscle or horizontal incision at the level of hyoid
bone, two nger breadths below the angle of mandible.
2. Transoral approach could be considered with ipsilateral tonsillectomy if the par-
apharyngeal abscess is high up and close to the tonsil and lateral to superior
constrictor muscle.
3. Carefully dissect through the subplatysmal and investing fascia to reach the
carotid sheath.
4. Retract the carotid sheath and its contents laterally to expose the parapharyn-
geal space.
5. Slide a nger along the posterior belly of digastric and stylohyoid muscles to
reach the styloid process in the parapharyngeal space.
6. Incise the fascia overlying the abscess and drain the pus.
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S. Mallick et al.
7. Break up loculations and irrigate with saline.
8. Place a drain if necessary to facilitate ongoing drainage.
Retropharyngeal abscess drainage:
1. Perform a transoral or transcervical approach or both, depending on the location
and size of the abscess and the patient’s anatomy.
2. Transoral approach: Under direct visualization, incise the posterior pharyngeal
wall at the point of maximum bulging. Drain the pus and irrigate with saline.
3. Transcervical approach: Make an incision along the anterior border of the ster-
nocleidomastoid muscle, and dissect to reach the retropharyngeal space.
4. Locate carotid sheath:
• Identify the sternocleidomastoid muscle; the carotid sheath is located medial
to it, containing the carotid artery, internal jugular vein, and vagus nerve.
5. Identify middle thyroid vein:
• Locate the vein as it drains from the thyroid gland into the internal jugular vein.
• Ligate the vein early in the procedure to allow for medial mobilization of the
thyroid gland, facilitating access to deeper neck structures.
6. Medialize thyroid gland:
• Following ligation of the middle thyroid vein, carefully mobilize the thyroid
gland medially.
• This step provides the necessary space to access the deeper planes leading to
the retropharyngeal space.
7. Access retropharyngeal space:
• Continue dissection medially behind the pharynx, carefully navigating
through the fascial planes.
• The carotid sheath lies lateral to the retropharyngeal space. This means that
when accessing the retropharyngeal space, the dissection is generally performed medially (towards the midline) away from the carotid sheath to prevent injury to its contents.
• Reach the retropharyngeal space by dissecting posterior to the pharyngeal
musculature.
• Incise the fascia overlying the abscess, drain the pus, and irrigate with saline.
If extended to mediastinum, the incision can be extended down to the
level of T4.
8. Place a drain if necessary to facilitate ongoing drainage.
Important Points to Note During the Surgery
• Understand the relevant anatomy, including the location of major blood vessels,
nerves, and other structures.
• Be prepared to manage potential complications, such as bleeding or airway
compromise.
• Monitor the patient closely for any signs of complications or recurrence of
infection.
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183
Questions a Consultant Might Ask a Trainee About the Operation
1. What are the boundaries of the parapharyngeal space?
The parapharyngeal space is bordered by the skull base superiorly; the hyoid
bone inferiorly; the parotid gland, digastric, and lateral pterygoid laterally; the
superior constrictor medially; retropharyngeal space posteromedially; and
carotid sheath posterolaterally. It is bounded anteriorly by pterygomandibular
raphe. It is divided into anterior (prestyloid) and posterior (poststyloid) compartments by the styloid process and its associated muscles.
2. What are the main sources of infection for peritonsillar, parapharyngeal,
and retropharyngeal abscesses?
Peritonsillar abscesses usually arise from an infection of the tonsil or peritonsillar tissue, often as a complication of acute tonsillitis/quinsy. Parapharyngeal
abscesses may result from infections in the teeth, tonsils, parotid gland, or pharynx or from penetrating trauma. Retropharyngeal abscesses can occur from
infections in the nasopharynx, oropharynx, or paranasal sinuses or from penetrating trauma or instrumentation.
3. What are the most common organisms causing deep neck infections?
Deep neck infections are commonly polymicrobial, involving aerobic and
anaerobic bacteria. The most common organisms include Streptococcus pyo-
genes, Staphylococcus aureus, Haemophilus inuenzae, and anaerobes such as
Prevotella, Fusobacterium, and Bacteroides species.
4. What are the potential complications of untreated or inadequately treated
deep neck infections?
Complications may include airway compromise, sepsis, mediastinitis,
carotid artery erosion or thrombosis, jugular vein thrombosis (Lemierre’s syndrome: septic thrombophlebitis of the internal jugular vein and metastatic
abscesses), necrotizing fasciitis, aspiration pneumonia, empyema, and abscess
extension into the neck, thorax, or cranium. Cranial nerve involvement and
carotid blowout are rare complications.
5. How can you differentiate between a peritonsillar abscess and peritonsillar
cellulitis?
Peritonsillar cellulitis is an inammation of the peritonsillar tissue without
the formation of a discrete abscess. Patients with peritonsillar cellulitis typically present with fever, sore throat, and mufed voice but lack the uctuance
or distinct mass associated with an abscess. Trismus is also much more associated with the abscess formation due to irritation of the pterygoid muscle.
Additionally, imaging studies such as CT or ultrasound can help differentiate
between cellulitis and an abscess by revealing the presence or absence of a uid
collection.
6. How is the parapharyngeal space divided?
It is divided into two parts by the fascial condensation called the aponeurosis
of Zuckerkandl and Testut (stylopharyngeal fascia) joining the styloid process
to the tensor veli palatini.
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S. Mallick et al.
7. What are the contents of parapharyngeal space?
• Prestyloid: deep lobe of parotid, medial pterygoid muscle, and mandibular
division of trigeminal nerve
• Poststyloid: IJV; ICA; cranial nerves IX, X, XI, and XII; and sympathetic trunk
8. What are the layers between the posterior pharyngeal wall vertebrae?
From anterior to posterior: buccopharyngeal facia → retropharyngeal
space→prevertebral fascia→prevertebral space.
9. What is the most common route of spread of infection to retropharyngeal
space in children?
In young children, retropharyngeal abscess may occur due to upper respira-
tory tract infection spreading to medial retropharyngeal lymph node of Henle.
These lymph nodes become rudimentary in the later childhood.
10. What should you request in your microbiology form?
Culture and sensitivity including anaerobic, TB, and atypical mycobacteria
(due to the possibility of cold abscess especially in the retropharyngeal abscess)
6.6 Cortical Mastoidectomy
Indications for Surgery [6]
• Chronic or recurrent mastoiditis unresponsive to medical treatment
• Cholesteatoma
• Complications of otitis media (e.g. brain abscess, lateral sinus thrombosis)
• Access for cochlear implantation
• Access to the facial nerve in facial nerve decompression surgery
Specific Risks Involved with the Surgery [6]
• Injury to the facial nerve
• Hearing loss
• Dizziness or vertigo
• Infection
• Bleeding
• Cerebrospinal uid leak
• Meningitis
• Anaesthesia complications