Oxford Handbook of ENT and Head and Neck Surgery (2 edn)
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How to cauterize the nose
Always ensure that you have performed adequate first aid steps before attempting to pack or cauterize the nose (
see ‘Epistaxis’, p. 374).
Procedure
Apply one or two cotton buds or a dental roll soaked in 1:200 000 adrenaline or 5% cocaine solution to the area, and apply pressure for at least 2 minutes.
Silver nitrate sticks may be applied to the bleeding point for one or two seconds at a time. Avoid using this form of cautery if the nose is actively bleeding since the blood will simply wash the chemical away. In addition to being ineffective, this will cause unwanted burns to the lips, nose, or throat. Instead, wait for the vasoconstrictive effects of the cocaine to work, and then apply pressure to the bleeding point. This will nearly always stop the bleeding temporarily before cautery.
Apply the silver nitrate in a circle starting a few mm from the bleeding point. This will allow any feeding blood vessels to be dealt with prior to cauterizing the main bleeding vessel.
It may be necessary to reapply the adrenaline- or cocaine-soaked cotton wool to reduce the bleeding between attempts at cautery.
If the nose is still bleeding, reapply pressure and consider packing the nose.
Electro- or hot-wire cautery may be used to good effect in experienced hands.
How to pack the nose
NB Always ensure that you have performed adequate first aid steps before attempting to pack or cauterize the nose ( see ‘Epistaxis’, p. 374).
When packing the nose, the aim is to put pressure on the bleeding vessel and prevent an active haemorrhage, so that the normal thrombotic mechanisms can act. Nasal packs are usually left in place for 24–48h. They must be secured anteriorly to prevent them falling back into the airway. Prophylactic antibiotics are often used. Patients should be admitted and are often lightly sedated. Different methods and materials are used to pack the nose.
Anterior nasal packing
Nasal tampons
The use of nasal tampons is the simplest way to pack the nose ( see Fig. 23.1). They consist of a dry sponge, which is placed into the nasal cavity and then hydrated with water or saline. The sponge then dramatically increases in size, putting pressure on the bleeding area. The nasal tampon should be lubricated with a little antibiotic cream (Naseptin®). The tip of the nose is simply lifted and the tampon slid into the nasal cavity, ensuring that it is passed parallel to the floor of the nose and not towards the top of the head. A little water or saline is then dripped onto the tampon, which is secured by taping the attached string to the face.
Nasal tampons.
BIPP packing
In this procedure, bismuth iodine and paraffin paste is used to impregnate a length of ribbon gauze. This mixture is antiseptic. Some skill and a good light is needed to place this form of nasal pack effectively. Topical analgesia, such as cocaine spray, is essential prior to packing.
Posterior nasal packing
Epistaxis balloon or urinary catheter
A variety of special nasal balloons are available ( see Fig. 23.2). They are easy to insert and are particularly helpful when the bleeding point is posterior. A Foley urinary catheter is also effective. This is passed into the nasopharynx, inflated, and then pulled anteriorly so that it occludes the posterior choana. It is prevented from slipping back into the nasopharynx or mouth by means of a clamp, which is placed at the nasal vestibule. It is important to put some padding between the skin and a clamp to ensure no pressure damage is caused. Additional anterior nasal packs may be inserted as above where needed.
Epistaxis balloons.
How to remove foreign bodies
You will need:
A good light
A co-operative patient
Good equipment
The first attempt will usually be the best tolerated. If you are not confident that you will be able to remove the foreign body, refer to ENT for more experienced help.
Foreign bodies in the ear
Signs and symptoms
Pain
Deafness
Unilateral discharge
Bleeding
May be symptomless
Management
Children will usually require a general anaesthetic unless they are remarkably co-operative.
Insects may be drowned with olive oil.
Syringing may be used if you can be certain there is no trauma to the ear canal or drum.
Use a head lamp or mirror, an operating auroscope or an operating microscope.
Soft foreign bodies such as cotton wool may be grasped with a pair of crocodile or Tilley’s forceps.
Solid foreign bodies, such as a bead, are best removed by passing a wax hook or Jobson–Horne probe beyond the foreign body and gently pulling towards you.
Refer to senior staff ± GA if:
Failed attempt
Unco-operative child
Suspected trauma to the drum
Foreign bodies in the nose
Signs and symptoms
Unilateral foul-smelling discharge
Unilateral nasal obstruction
Unilateral vestibulitis
Epistaxis
Management
An auroscope can easily be used to examine a child’s nose.
Ask the child to blow their nose if they are able.
Solid foreign bodies such as beads are best removed by passing a wax hook or Jobson–Horne probe beyond the foreign body and gently pulling it towards you. Avoid grasping the object with a pair of forceps, since this may simply push it further back into the nose or airway.
Soft foreign bodies may be grasped and removed with crocodile or Tilley’s forceps.
Refer to senior staff if:
Failed removal
Unco-operative child
Foreign bodies in the throat
Signs and symptoms
Acute onset of symptoms (not days later)
Constant pricking sensation on every swallow
Drooling
Dysphagia
Localized tenderness in the neck, if above the thyroid cartilage then look carefully in the tongue base and tonsil regions
Pain on rocking the larynx from side to side
Soft tissue swelling
Management
Use a good light to examine the patient.
Anaesthetize the throat using Xylocaine spray.
Try feeling for a foreign body (FB) even if you cannot see one in the tonsil or tongue base.
Flecks of calcification around the thyroid cartilage are common on X-ray.
Perform an AP and lateral soft tissue X-ray of the neck, looking for foreign bodies at the common sites ( see Fig. 23.3). Pay particular attention to the:
tonsil
tongue base/vallecula
posterior pharyngeal wall.
Tilley’s forceps are best for removing foreign bodies in the mouth.
McGill’s intubating forceps may be useful for removing foreign bodies in the tongue base or pharynx.
Lateral soft tissues X-ray of the neck.
Refer for endoscopy under GA in case of:
Airway compromise—URGENT
Failed removal
Good history but no FB seen
X-ray evidence of an FB
How to syringe an ear
( See Fig. 23.4.) Check that the patient has no previous history of TM perforation, grommet insertion, middle ear or mastoid surgery.
How to syringe an ear.
Procedure
Warm the water to body temperature
Pull the pinna up and back
Use a dedicated ear syringe
Aim the jet of water towards the roof of the ear canal
STOP if the patient complains of pain
How to dry mop an ear
A dry mop should be performed in any ear which is discharging, before topical antibiotics and steroid ear drops are instilled.
Procedure
Tease out a clean piece of cotton wool into a flat sheet.
Twist this onto a suitable carrier such as an orange stick, a Jobson–Horne probe, or even a clean matchstick ( see Fig. 23.5).
Gently rotate the soft end of the mop in the outer ear canal.
Discard the cotton wool and make a new mop—continue until the wool is returned clean.
Diagram of an ear mop.
How to instil ear drops
See Fig. 23.6.
How to instil ear drops.
Procedure
Lie the patient down with the affected ear uppermost.
Straighten the ear canal by pulling the pinna up and back.
Squeeze in the appropriate number of drops.
Use a gentle pumping motion with your finger in the outer ear canal. This will encourage the drops to penetrate into the deep ear canal.
Consider using an ‘otowick’. This is like a preformed sponge and it acts as a reservoir, helping to prevent the drops leaking out of the ear canal. An otowick is particularly useful in otitis externa.
How to drain a haematoma of the pinna
This usually occurs after direct trauma to the pinna. It is often caused by a sports injury such as boxing or rugby. If left untreated it may leave a permanent deformity such as a ‘cauliflower’ ear.
Do not neglect the associated head injury which may take priority over the ear injury.
Procedure
Aspiration may be satisfying, but the collection nearly always reforms, so it is probably best avoided.
Refer for drainage under sterile conditions.
Incise the skin of the pinna under local anaesthesia in the helical sulcus ( see Fig. 23.7).
Milk out the haematoma.
Do not close the wound.
Apply pressure to the ear to prevent recollection. Either pack the contours of the ear with proflavine or saline-soaked cotton wool, and apply a head bandage. Alternatively, use a through and through mattress suture tied over a bolster or dental roll.
Give antibiotics.
Review in 4–5 days.
Haematoma pinna incision.
How to drain a quinsy
Signs and symptoms
Sore throat—worse on one side
Pyrexia
Trismus
Drooling
Fetor
Peritonsillar swelling
Displacement of the uvula away from the affected side ( see Fig. 23.8)
Quinsy/incision/aspiration.
Procedure
This procedure usually requires admission.
Rehydrate with IV fluids.
Give IV antibiotics.
Spray the throat with lidocaine 10% spray or inject lidocaine into the mucosa as shown.
Lie the patient down.
Get a good light and a sucker.
Use a 5ml syringe and a large bore needle or IV cannula to perform 3-point aspiration ( see Fig. 23.8).
Send any pus obtained to microbiology for culture.
Reserve incision for those cases that recur or fail to resolve within 24h.
How to perform fine needle aspiration cytology (FNAC)
Procedure
Lie the patient down.
Clean the skin with alcohol.
Fix the lump between your finger and thumb.
Use a fine needle (blue or orange) attached to a 10ml syringe.
Pass the needle into the lump.
Apply suction.
Move the needle back and forth through the lump using small vibration-type movements—this can prevent contamination by sampling other tissues.
Make some rotary movements in order to remove a small core of tissue.
Release the suction.
Then remove the needle.
Detach the needle from the syringe and fill it with air.
Replace the needle and expel the contents onto a microscope slide.
Remove the needle and repeat as necessary.
Check the inside of the barrel of the needle for any tissue which may have become lodged there.
Take a second slide and place it on top of the first, sandwiching the sample between the two.
Briskly slide the two apart, spreading the sample thinly and evenly.
Fix and label the slides.
