Consultant Otolaryngology (ENT) oral assessment prep

Knowledge: This is a secondary post-tonsillectomy haemorrhage, typically occurring between day five and day ten as the eschar separates, usually associated with local infection, and it is more common after hot techniques than cold dissection. The visible ooze understates the true blood loss because children swallow blood, and paediatric compensated shock is deceptive: tachycardia, delayed capillary refill and narrowed pulse pressure precede hypotension, and a normal blood pressure in a child is a late and reassuring-looking sign that can mislead the unwary.

Management: I would sit her up, keep her calm with a parent present, apply oxygen, secure two large-bore cannulae, take blood for full blood count, coagulation screen, group and cross-match at least two units, and give a fluid bolus of 10 to 20 mL/kg of balanced crystalloid, repeated and escalating to blood if she remains tachycardic, using the paediatric major haemorrhage protocol if needed.

Ethics and communication: Consent must be obtained from a parent, but it is being taken under duress from frightened parents at midnight, so I would keep it focused and honest, explain the need for immediate anaesthesia, the risks of anaesthesia in a bleeding child including aspiration, the risk of further bleeding and re-operation, and the small possibility of blood transfusion, documenting the discussion and the time.

Reference: AAO-HNS Clinical Practice Guideline: Tonsillectomy in Children (Update), Otolaryngology-Head and Neck Surgery (2019); ENT UK / national tonsillectomy audit standards; Scott-Brown's Otorhinolaryngology, 8th edition (2018).

Knowledge: This is posterior epistaxis, indicated by bleeding into the oropharynx and by failure of a correctly placed anterior pack, and in an elderly anticoagulated patient with anaemia it is a resuscitation problem, not just a nasal one. The usual source is the sphenopalatine artery or its branches, and less commonly the anterior or posterior ethmoidal arteries; hypertension does not cause epistaxis but sustained high pressure and anxiety make control harder, so calming him and treating pain will help.

Management: I would resuscitate first: sit him up, oxygen, two wide-bore cannulae, bloods including full blood count, group and save with cross-match of two units, urea and electrolytes, coagulation and an anti-Xa assay if available, and transfuse to a threshold appropriate for his cardiac disease, generally aiming above 8 g/dL given his ischaemic heart disease, with careful attention to fluid overload.

Ethics and communication: He is frightened, elderly and pulling at his pack, so I must judge whether that is distress and delirium rather than refusal, assess his capacity in the moment, and use the least restrictive approach with clear explanation, family presence and adequate analgesia before considering any restraint, which should be avoided.

Reference: AAO-HNS Clinical Practice Guideline: Nosebleed (Epistaxis), Otolaryngology-Head and Neck Surgery (2020); ESC/EHRA practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation (2021).

Knowledge: This is an impending complete airway obstruction from a supraglottic tumour, and the cardinal principle is that I must not convert a partially obstructed but self-ventilating patient into an apnoeic one I cannot oxygenate. Biphasic stridor, drooling, tripod posture, use of accessory muscles, an inability to lie flat and a rising respiratory rate with falling saturations indicate that decompensation is imminent, and hypoxia rather than hypercapnia will kill him first.

Management: I would go to the patient immediately, keep him upright and calm, apply high-flow humidified oxygen or heliox if available, give intravenous dexamethasone and nebulised adrenaline, obtain intravenous access and monitoring, and avoid sedation and lying him flat.

Ethics and communication: Consent here is necessarily brief and urgent, and it must still be real: I would tell him in a few clear sentences that he needs a hole in the neck to breathe, that he will not be able to speak normally afterwards, and that without it he may die tonight, and I would document that discussion including his capacity, the time and the witnesses.

Reference: Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults; National Tracheostomy Safety Project emergency algorithms (2012); Scott-Brown's Otorhinolaryngology, 8th edition (2018).

Knowledge: This is a wrong-site surgery, a recognised never event, and the immediate issues are the anaesthetised patient's safety, the absence of valid consent for anything further, and the integrity of the record. The check that failed is the multi-step universal protocol: site marking by the operating surgeon with the awake patient before premedication, verification against the consent form, the audiogram and the imaging, and the WHO surgical safety checklist time-out immediately before incision with the whole team stopped and engaged.

Management: I would stop the process there, calmly and without an argument in front of the team, and ask the surgeon to step aside with me for thirty seconds. My position would be that the left wound is closed properly with meticulous haemostasis and a standard dressing, no further surgery is performed, the patient is woken safely and recovered, and the right ear is rescheduled after a fresh consent discussion. I would ask the anaesthetist and the theatre coordinator to be part of that decision so it is a documented team decision rather than an instruction.

Ethics and communication: The patient must be told, fully and promptly, by a senior clinician, ideally the operating surgeon supported by me or the head of department, as soon as he is awake and able to understand, with a relative present if he wishes.

Reference: WHO Guidelines for Safe Surgery and the WHO Surgical Safety Checklist (2009); The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery (2003, current edition).