EENT Flashcards
Viral/bacterial versus allergic conjunctivits presentation
Viral/bacterial= PAINFUL red eyes, gritty eyes no visual change
Allergic= always bilateral, itching
Presentation of chlamydial versus gonoccal opthalmia neonatorum
Gonococcal- within 48 hours get discharge, conjunctivits and swelling eyelids
Chlamydia- 1-2 weeks of life get discharge, conjunctivitis, swelling eyelids and !pneumonia!
Gold standard investigations for different conjunctivitis
- viral
- bacterial
- gonoccoal
- chlamydia
Viral- adenovirus immunoassay
Bacterial- swab MC&S
Gonoccal- gram stain and culture
Chlamydia- immunofluorescent staining
First investigation when swollen eyes
Urine dip to check for protein
Complications of otitis media
Perforation
Mastoiditis
Meningitis
Abscesses
Recurrences
Most common causes of AOM
RSV or rhinoviruses
Strep p
Hib
Management of AOM
Admit if needed
Paracetamol and NSAID recommendation
Fluids advice
In patients very unwell then give abx
In patients who may benefit from abx (bilateral infection under 2 or otorrhoea) give immediate course, back-up course or no abx
In patients less likely to benefit from abx either back-up course or no abx
MAINLY TREAT IF COURSE GREATER THAN 3 DAYS
When admit for AOM
Severe systemic infections
Complications
Younger than 3 months and fever over 38
Consider
- under 3 and fever under 38
- 3-6months with fever over 39
Antibiotics for AOM
1st line- amoxicillin
2nd line/penicillin intolerant- macrolide
If does not respond in 2-3 days use co-amox and in this scenario if penicillin allergic seek micro advice
Management of AOM with tympanic membrance perforation
Oral amoxicillin and review in 6 weeks to check healing
If downs or cleft palate refer
What is choanal atresia
When nasal passages fail to form
Can be unilateral or bilateral
Management of choanal atresia
Unilateral- none
Bilateral- surgical
Difference in presentation of unilateral versus bilateral choanal atresia
Unilateral- asymptomatic or rhinorrhoea
Bilateral- choking when feeding, cyanosis when feeding, relieved by crying
What presents with choking on feeding, cyanosis on feeding and relieved by crying
Choanal atresia
Most common cause of stridor in infants
Laryngomalacia
What hearing test is done in newborns
Otoacoustic emission test- can be done up to 3 months
What is hearing test do if otoacoustic emission test shows problem
Brainstem auditory response
What is a squint
Misalignment of the eyes- common up to 3 months of age
Management of squint
Check red reflex
If over 3 months refer to opthalmologist
What are the 2 types of squint
Concomitant- one eye diverges typically inwards
Paralytic- varies with gaze direction
Which type of squint are most concerned about
Paralytic- varies with gaze direction due to paralysis of motor nerves
Suggests SOL
What covers outer middle and inner ear
Outer ear- outside and most of ear canal
Middle- tympanic membrance
Inner- eustachian tube
Presentation of otitis externa
Irritable
Otalgia getting worse
Ottorhoea
Ear fullness with hearing loss
Tinnitus
Itchy
RIsk factors for otitis externa
Females
Swimmer
Eczema and psoriasis
Foreign body in ear
Bacterial otitis externa on otoscopy
Narrow ear canal
Tympanic membrane not visible
Swollen and erythematous
Yellow and white crusted edge
Fungal otitis externa on otoscopy
Narrow ear canal
Tympanic membrane not visible
Swollen and erythematous
White and grey spores
Most common cause of otitis externa
List some other causes
Most common pseudomonas aeruginosa
- s aureus
- s epidermis
- aspergillus
Management of otitis externa
If very mild- Hygiene measures
- avoid swimming for 10 days
- dont clean ears
If more severe
- topical antibiotic/antifungal with or without topical corticosteroids
If immunocompromised or severe infection
- oral flucloxacillin
Difference in management of bacterial versus fungal otitis externa
Bacterial- neomycin drops for 10-14 days
Fungal- clotrimazole drops for 6 weeks
3 main complications of AOM
Tympanic membrance perforation
Mastoiditis
Otitis media with effusion
How will tympanic membrane perforation present
Discharge from ear after baby became well
How does mastoiditis present
Bulging/protruding ear
Very red behind the ear
Management of acute mastoiditis
Refer immediately to ENT for IV abx
Abx ear drops
CT of petrous bone and brain
If very severe consider myringotomy or mastoidectomy
What is guideline for needing grommet in recurrent AOM
Grommet tube- allows ventilation between middle and inner ear
Causes of tympanic membrane perforation
Loud sounds
Head trauma
Infection
Foreign bodies
Management of tympanic membrane perforation
Small perforations- watch and wait
Large- surgical repair
Management of OME
Watchful waiting for 3 months recommended but still do hearing tests
- pure tone audiometry 3 months apart
- tympanometry
Determine if need referral to ENT
What is done if referred to ENT with OME
Non surgical
- hearing aids
- autoinflation
Surgical
- myringotomy or grommets
- adenoidectomy
Why is OME important
Hearing loss can cause speech development delay
If a child over 4 has a grommet tube put in what is done for them
Adenoidectomy too
What is a cholesteatoma
A granuloma
Where squamous epithelium migrates in the middle ear eating away at the bone and soft tissue
Presentation of cholesteatoma
Persistent smelly discharge which antibiotics do not help
Progressive hearing loss
Dizziness
Facial palsy
Cholesteatoma on otoscopy
Perforated ear drum
Dry skin like webs
How to investigate a cholesteatoma
Otoscopy
Diffusion weighted MRI
How is cholesteatoma managed
Mastoidectomy
Risks of cholesteatoma
Facial nerve palsy
Hearing loss
Spread of infection
How should foreign bodies be removed in ear
First try to remove self- is best chance
If not refer to ENT for removal with ENT microscope
If unsuccessful will need general anaesthetic as children can become very agitated
What things should be removed from ear immediately within 6 hours
Battery
Glue
Corrosive material
What things should be removed from ear on same day
Food matter
Insects
What things can be removed at next available appointment
Cotton buds
Beads
Inorganic harmless objects essentially
How does pinna haematoma present
Boggy bluish swelling of the pinna after contact sport or piercing
Management of pinna haematoma and why important
Urgent drainage under GA
Apply pressure dressing
Long term will lead to cauliflower ear
How are otoacoustic emission and auditory brainstem response carried out
Automated otoacoustic emission
- earpiece inserted and echo measured in microphone
Automated brainstem response
- electrodes on band aids placed on the babies head and sound played into babies ears, computer measures response
When would you be concerned about nose bleeds in children
Under 2s as very rare then
Suggest abuse
Risk factors for nose bleeds
Clotting disorders
Trauma
Male
Winter
Nasal allergies
Mangement of nose bleed
ABCDE
Position with head held forward
If persists beyond 15 mins use topical lidocaine, adrenaline or transamic acid
If does not control can cauterise
What is adenoidal hypertrophy
Adenoidal tissue sits at back of the nasal cavity
When exposed to allergens get hypertrophy
Presentation of adenoidal hypertrophy
Persistent mouthy breathing
Hyponasal speech
OSA
Recurrent otitis media or OME
Complication of adenoidal hypertrophy
Recurrent AOM and OME
Management of adenoidal hypertrophy
If severe adenoidectomy
With or without tonsillectomy and grommet insertion
presentation of allergic rhinitis
Swollen and itchy eyes
Runny nose
Tickly throat
Allergens to allergic rhinitis
Pollen
Smoke
Dust
Spores
What type of reaction is allergic rhinitis
Type 1 hypersensitivity- associated with being first born child, asthma and atopy
Problems of allergic rhinitis
Concentration at school
Sleep affected
How is diagnosis of allergic rhinitis confirmed
Skin prick test
Patch test
What is rhinosinusitis
Acute inflammation of the nose and paranasal sinuses from rhinovirus
How does rhinosinusitis present
Headache
Nasal obstruction
Rhinorrhoea with post nasal drip
Fever
How is sinusitis diagnosed in children
Nasal blockage
Discoloured nasal drip anteriorly or posteriorly
Pain in face or headache
When suspect bacterial sinusitis
Severe unilateral pain
Prurulent nasal discharge with unilateral predominance
Fever over 38
What are causative agents of sinusitis
Rhinovirus
Coronavirus
Bacterial infection in 2% of cases
When admit for sinusitis
Signs of meningitis
Focal neurology
Systemic infection
Intraorbital/periorbital infection
Management of sinusitis if less than 10 days
No antibiotics
Use paracetamol or ibubrofen
Can consider nasal decongestant or washing with salt water
Management of sinusitis if over 10 days
If over 12 prescribe high dose nasal corticosteroids (mometasone)
Consider back up antibiotics to be used if symptoms do not improve within 10 days
If severe illness or comlpications prescribe oral coamoxiclav
Antibiotics given in sinusitis first line
Phenoxymethicillin for 5 days
If allergic or intolerant clarithomycin but can use doxy if over 12
Second line abx if not responsive in first few days of sinusitis antiobtics
Co-amoxiclav
What is difference between periorbital and orbital cellulitis
Orbital (also known as post septal) orginates from infection from frontal or ethmoid sinuses
Periorbital (preseptal) arises from infection of eye lids or nearby skin
Complications of orbital and periorbital cellulitis
Cavernous sinus thrombosis
Erosion of orbital bones
Brain abscess
Meningitis
What worried about especially in orbital cellulitis
Can result in compartment syndrome leading to optic nerve compression
Management of orbital versus preiorbital cellulitis in terms of referral
Orbital- ENT
Peri- derm
Presentation of orbital cellulitis
Prodrome URTI
Proptosis
Acute swelling of eye
Restricted eye movement- important to document throughout
How should periorbital cellulitis be investigated
Swab
CT head
Management of orbital cellulitis
Contrast CT scan of face
IV co-amoxiclav
Management of periorbital cellulitis
Refer immediately
IV abx
Management of nasal foreign body
Must be done in the same day as risk of lung inhalation
If cant be done in ED need to do under GA
Pharyngitis versus tonsillitis examination
Pharyngitis- pharyngeal exudate and cervical lympahdenopathy
Tonsilitis- anterior cervical enlargement and tonsil exudate
When to treat tonsilitis/pharyngitis
Do fever pain or centor
If FPAIN over 4 or centor over 3
Consider antibiotics- phenoxymethicillin
Lower threshold if increased risk of rheumatic fever, immunosuppressed or compromised
Antibiotics for tonsillitis/pharyngitis
Phenoxymethicillin for 5 days
Clarithomycin if allergic for 5 days
Erythomycin if pregnant
When refer with sore throat
Breathing difficulty
Abscesses or cellulitis
Suspected sepsis or kawasaki or diptheria
What do in sore throat if on DMARD and carbimazole
Work out FBC
Withold drug until available
When refer for tonsillectomy
7 episodes in a year
5 a year over 2 years
3 a year over 3 years
Complications of tonsillitis
Local spread
- quinsy
- retropharyngeal abscess (under 5)
- parapharyngeal abscess
Rheumatic fever
Glomerulonephritis
Complications of parapharyngeal abscesses
Mediastinitis
Venous thrombosis
What is quincy and how identify on patient
Peritonsilar abscess
How are parapharyngeal abscesses identified
Unilateral neck swelling
Causes of pharyngitis
Viral diseases- flu and measles
EBV
Strep A
Typhoid
Cocksackie- HFM
Diphteria
What do if post tonsillectomy bleed
Admit everyone to ENT
As risk of airway obstruction and shock
A-E
- lean head forward
- lidocaine/transexamic acid/adrenaline
- hydrogen peroxide gargles
Classification of post tonsillectomy bleeds
Primary- within 10 days
Secondary- after 10 days
Presentation of foreign body aspiration
Short sudden episode of resp distress, cyanosis then alright
Stridor
Unilateral wheezing
Comlpications of foreign body aspiration
Airway obstruction
Lung abscess
Fistula formation
What is stertor
Snoring
Much harsher compared to stridor
How to diagnose foreign body inhalatoin
Lateral and AP chest X-ray
Ideally lateral
Management of foreign body ingestion
Admit for period of observation then let go with safety net
- fever
- pain
- constipation over 24 hrs
- poor sleep, crying
Some objects will pass naturally but others will require surgical removal
How does laryngomalacia present
Stridor worse when lying down
Difficulty breathnig
Poor oral intake/choking
What is laryngomalacia
When larynx floppy or malformed
Usually present in first month of life and will resolve by 2 years
When is laryngomalacia referred urgently
Neck and chest retractions
Apnoea events
Failure to thrive
Secondary heart or lung problems
Blue spells
What is lymphadenitis
Enlargement of cervical lymph nodes secondary to inflam condition
Presentation of lymphadenitis
Tired child off food
Enalrging neck lump
Tender
Hot erythematous
What does fluctuant neck lump suggest
Abscess secondary to lymphadenitis
Difference between sensorineural and conductive hearing loss
Sensorineural- lesion in cochlear or auditory nerve
Conductive- abnormalities of the middle ear
Sensorineural causes of hearing loss
Genetic
Antenatal
- kernicterus
- congenital infection
- HIE
Post natal
- meningitis
- head injury
Causes of conductive hearing loss
OME
Eustachian tube dysfunction
- downs
- cleft palate
Wax very rarely
Prognosis of conductive versus sensorineural hearing loss
Sensorineural- does not improve and may progress
Conductive- intermittent or resolves
Management of sensorineural hearing loss
Hearing aids
If does not work can use cochlear implant
School management of hearing loss
If moderate impairment can be educated in school system but advised to sit at front
If profound will need to attend school for deaf children
Management of allergic rhinitis
Avoid allergen and cetirizine
If very severe encourage desensitisation through graded exposure
What is a myringotomy and grommet insertion
Myringotomy involves piercing hole through tympanic membrane and allowing fluid out
Grommet physical tube to allow fluid out
Managment of a burst eardrum
Will heal by self
Advise about
- hot towels
- avoiding loud sounds
- blowing nose too hard
Safety net about signs of infection
Side of neck swelling differentials in a child
Mumps- bilateral
Lymphadenitis
Lymphoma
Parapharyngeal abscess from tonsillitis
When refer to opthal with conjunctivitis
Suspect herpetic
Opthalmia neonatorum
Unresponsive to treatment after a week
Suspect orbital or periorbital cellulitis
Management of bacterial conjunctivits
Advise about handwashing
If severe chloramphenicol or fusidic acid drops
If not that bad can give back-up
Management if re-attend with conjunctivitis symptoms not disappearing
Send swabs for adenovirus, herpes and cultures
Management of suspected viral conjunctivits
Will resolve in 2 weeks
Warm dress with saline for symptoms
Send swabs if return to GP with symptoms
When suspect herpetic conjunctivits
It causes a blepharoconjunctivitis typically
Ulcers on periocular skin
Refer to opthal
Differentials for loss of red reflex
Cataracts
ROP
Retinoblastoma
What do if OME persists beyond 12 weeks
Refer to ENT
What is in fever pain
F- fever in last 24 hours
A- absence of cough
P- prurulent discharge
S- symptoms over 3 days
S- severe inflammation
Management of different F-Pain scores
Under 2 do nothing
2-3- delayed antibiotics
4 or more- give abx
What is otitis media with effusion
Where after infection get build up of fluid in middle ear space
When can chemo be used instead of enucleation in retinoblastoma
No anterior chamber involvement
No glaucoma
No inflammation
Main indications for giving antibiotics for AOM
under 2 and bilateral
Under 3 months
For over 3 days
Immunocompromised
