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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3998_Библиотеки_им_академика_М_И_Перельмана
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Ear, nose and throat (ENT)
Chris Coulson, Adrian Drake-Lee
NOSE: EPISTAXIS
Questions 71
Clinical cases 71
OSCE Counselling cases 72
Key concepts 73
Answers 74
Clinical cases 74
OSCE Counselling cases 77
Revision panel 77
UNILATERAL NASAL DISCHARGE
Questions 78
Clinical cases 78
OSCE Counselling cases 79
Key concepts 80
Answers 81
Clinical cases 81
OSCE Counselling cases 83
Revision panel 83
NASAL OBSTRUCTION
Questions 84
Clinical cases 84
OSCE Counselling cases 85
Key concepts 86
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68 Ear, nose and throat (ENT)
Answers 87
Clinical cases 87
OSCE Counselling cases 89
Revision panel 89
LANGUAGE DELAY AND DEVELOPMENT
Questions 90
Clinical cases 90
OSCE Counselling cases 91
Key concepts 92
Answers 94
Clinical cases 94
OSCE Counselling cases 96
Revision panel 96
ADULT EAR DISEASE
Questions 97
Clinical cases 97
OSCE Counselling cases 98
Key concepts 99
Answers 100
Clinical cases 100
OSCE Counselling cases 102
Revision panel 102
ADULT BILATERAL DEAFNESS
Questions 103
Clinical cases 103
OSCE Counselling case 104
Key concepts 105
Answers 106
Clinical cases 106
OSCE Counselling case 107
Revision panel 107
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Ear, nose and throat (ENT) 69
EARACHE
Questions 108
Clinical cases 108
OSCE Counselling case 109
Key concepts 110
Answers 111
Clinical cases 111
OSCE Counselling case 113
Revision panel 113
THE DIZZY PATIENT
Questions 114
Clinical cases 114
OSCE Counselling case 115
Key concepts 116
Answers 117
Clinical cases 117
OSCE Counselling case 120
Revision panel 120
ACUTE FACIAL PALSY
Questions 121
Clinical cases 121
OSCE Counselling case 122
Key concepts 123
Answers 124
Clinical cases 124
OSCE Counselling case 125
Revision panel 125
THROAT
Questions 126
Clinical cases 126
OSCE Counselling case 127
Key concepts 128
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70 Ear, nose and throat (ENT)
Answers 129
Clinical cases 129
OSCE Counselling case 131
Revision panel 131
DIFFICULTY IN SWALLOWING
Questions 132
Clinical cases 132
OSCE Counselling case 133
Key concepts 134
Answers 135
Clinical cases 135
OSCE Counselling case 136
Revision panel 136
HOARSE VOICE
Questions 137
Clinical cases 137
OSCE Counselling case 138
Key concepts 139
Answers 140
Clinical cases 140
OSCE Counselling case 142
Revision panel 142
PAINLESS NECK LUMP
Questions 143
Clinical cases 143
OSCE Counselling case 144
Key concepts 145
Answers 146
Clinical cases 146
OSCE Counselling case 148
Revision panel 148
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Nose: epistaxis 71
NOSE: EPISTAXIS
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What are the important ndings on examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.1 –
Adult with nosebleed
A 60-year-old retired man, who is on warfarin for a deep vein thrombosis (DVT), presents with a
profuse epistaxis to the accident and emergency (A&E) department. There is no other signicant history.
Examination shows that the patient is actively bleeding from the left side of the nose.
CASE 2.2 –
Child with nosebleed
A 7-year-old girl presents with intermittent bilateral epistaxis to the ENT clinic. Examination of the nose
reveals dilated veins anteriorly, but no obvious signs of any other pathology.
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72 Ear, nose and throat (ENT)
OSCE Counselling cases
OSCE COUNSELLING CASE 2.1 –
Adult with nosebleed.
What advice should you give to an adult male who is coming into hospital and has had his nose packed?
OSCE COUNSELLING CASE 2.2 –
A single mother has a child aged
3 years with profuse intermittent
nosebleeds, which occur at night.
The mother is concerned that her child might bleed to death. Can you assure her that this will not be
the case?
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Nose: epistaxis 73
Key concepts
Epistaxis is commonly the result of a localized nasal condition.
Epistaxis may be caused by a systemic problem.
Treat the condition locally and then investigate the patient.
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74 Ear, nose and throat (ENT)
Answers
Clinical cases
CASE 2.1 –
Adult with nosebleed
A1: What is the likely differential diagnosis?
Epistaxis can be due to a local condition or part of a systemic disease. Most cases are related to dilated
vessels on the anterior septum, Little’s area, this is the region where the three different vascular supplies
to the nose (sphenopalatine artery, ethmoid arteries and facial artery, via the superior labial artery)
converge (Figure2.1). Bleeding from Little’s area is especially common in younger adults; it occurs
occasionally from the posterior nasal cavity, typically in elderly patients, and is usually related to a recent
upper respiratory tract infection or direct trauma (nose picking). A nasal tumour may present with
unilateral epistaxis, although this is not profuse unless it erodes into an artery. The differential diagnosis
of systemic diseases causing epistaxis includes any lesion that might interfere with coagulation, including
diseases of the bone marrow and liver, and drugs that interact with the clotting cascade.
A2: What additional features in the history would you like to elicit?
Ask about a history of bruising or bleeding elsewhere, as this may indicate a bleeding diathesis. A full
general medical history should be taken on any patient who presents with epistaxis once the condition
has been treated, with particular reference to diseases (liver dysfunction) or therapies (antiplatelet
agents, aspirin or warfarin) that may interfere with clotting.
A3: What are the important ndings on examination?
Primary resuscitation measures involve assessing the degree of blood loss and the need for intravenous
uids. Pulse and blood pressure should be checked and aid in determining whether the patient is in
shock. The anterior nasal cavity should be examined to determine whether a bleeding point is visible,
and if it is, this can be cauterized.
Bony nasal rim
Little’s area
Anterior ethmoid artery
Superior labial artery
Posterior ethmoid artery
Sphenopalatine artery
Figure 2.1 Schematic diagram of blood supply to the anterior nose.
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Nose: epistaxis 75
A4: What investigations would be most helpful and why?
Investigations are undertaken after the patient has been assessed and active bleeding stopped if he or
she is admitted to hospital. A full blood count (FBC) should be undertaken at the time of bleeding. A
clotting screen should be performed to see whether the patient is over-anticoagulated or has a bleeding
diathesis.
A5: What are the treatment options?
Priority is to arrest haemorrhage and resuscitate a shocked patient. Initial management follows
an escalating scale of interventions, stopping only once the haemorrhage has arrested. Primary
management involves squeezing the anterior cartilaginous nose for 10 minutes (Figure2.2),
tamponading the vessels of the anterior septum, with the patient in a head-down, seated position
(ensuring ongoing epistaxis does not travel to the nasopharynx and on the pharynx and larynx).
This simple measure will stop most nosebleeds. Visual inspection of the anterior nose will permit
cauterization of the offending vessels. If this measure fails then nasal packing is required, and this
can be performed with a variety of substances, including BIPP (bismuth iodoform parafn paste) or
Merocel packs. Packing the nose is an uncomfortable procedure and should be undertaken under local
anaesthesia (Co-phenylcaine spray – 5 per cent aqueous solution of lignocaine and phenylephrine). If
the patient has been over-anticoagulated, correction of this is typically required. If the pack remains in
situ over 48 h antibiotic prophylaxis is required because a secondary sinusitis or toxic shock syndrome
may develop. All patients with packing should be admitted to the hospital because hypoxia, confusion
and inhalation of a pack may occur. Occasionally, operations are required if nasal packing is unsuccessful
such as correction of septal displacement so that the nose can be packed very tightly under general
anaesthesia or sphenopalatine artery ligation may be undertaken.
CASE 2.2 –
Child with nosebleed
A1: What is the likely differential diagnosis?
The differential diagnosis is the same as for Case 2.1. However, it is exceptionally rare for systemic
disease to present with epistaxis in a child, although acute leukaemia may present in this way. The
most common cause is dilated vessels in Little’s area where vessels from the internal (anterior and
posterior ethmoid arteries) and external (sphenopalatine artery and facial artery) carotid arteries
anastomose.
Figure 2.2 Schematic diagram of area of the nose to hold in epistaxis.
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76 Ear, nose and throat (ENT)
A2: What additional features in the history would you like to elicit?
Additional features in the history are those in Case 2.1. Bruising and other bleeding problems should
always be asked about in children with epistaxis. A full history of nasal symptoms such as crusting of the
anterior nose should also be taken.
A3: What are the important ndings on examination?
Primary resuscitation measures involve assessing the degree of blood loss and the need for intravenous
uids, pulse and blood pressure should be checked and aid in determining whether the patient is in
shock, although this is extremely unlikely in a child. The anterior nasal cavity should be examined to
determine whether a bleeding point is visible, and if it is, this can be cauterized.
A4: What investigations would be most helpful and why?
Unless systemic disease is suspected, no investigations are required. Occasionally, an FBC is needed if
the patient has bled actively and often; however, anaemia is very rare from epistaxis in children.
A5: What are the treatment options?
The treatment in children is slightly different from that in an adult as the cause in a child is often
vestibulitis resulting from frequent nose picking. This causes direct trauma to Little’s area. A course
of Naseptin cream (chlorhexidine hydrochloride and neomycin) to the anterior nasal vestibule on both
sides may settle any infection and resolve the condition as the child then picks the nose less frequently.
Simple cautery with silver nitrate is effective in over half the cases, and can be undertaken with or
without local anaesthesia. If the child is under 5 years old, it is better to perform cautery under general
anaesthesia, primarily to keep the child still, to ensure it can be completed effectively. Randomized
controlled trials demonstrate an equivalent efcacy for cautery and Naseptin. Parents should be warned
that children with epistaxis tend to get further bleeding in half of all cases.
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