ENT

Question 1

What are the three most common bacterial pathogens for ACUTE OTITIS MEDIA?

Answer 1

1. S. pneumoniae
2. H. influenza
3. M. catarrhalis

Question 2

Risk factors for ACUTE OTITIS MEDIA?

Answer 2

✔️ premature birth
✔️ male gender
✔️ not breastfed 
✔️ sibling with AOM
✔️ insufficient nutrition
✔️ overcrowding
✔️ poor hygiene
✔️ attends day care / kindergarten
✔️ poor access to healthcare

Question 3

Key otoscopic findings for AOM?

Answer 3

✔️ loss of light reflex
✔️ bulging tympanic membrane
✔️ reduced translucency
✔️ neovascularisation

N.B. air fluid level behind the tympanic membrane is suggestive of effusion

Question 4

Red flags for AOM suggestive of immediate antibiotic therapy?

Answer 4

✔️ child < 6 months of age
✔️ child < 2 years of age with bilateral AOM
✔️ any ATSI child
✔️ immunocomprised child
✔️ systemically unwell

Question 5

What is the treatment protocol for ACUTE OTITIS MEDIA?

Answer 5

1. If the child is mildly unwell and does NOT have any red flag symptoms, reassure the parent, advise oral analgesia (e.g. paracetamol) and follow up within 48 hours.
2. If the child does NOT improve after 48 hours, commence oral antibiotic therapy (amoxicillin 30mg / kg / BD for 5 days). Follow up in 48 hours.
3. If the child still does NOT improve in another 48 hours, commence amoxicillin + clavulanic acid 22.5mg / kg / BD for 5 days. Reconsider diagnosis and if there is another diagnosis that better explains symptoms.

Of course, if the child has any red flag signs or is an “at risk” group, commence antibiotic therapy immediately.

PARENTAL REASSURANCE - 50% of cases are caused by viruses; will NOT solve with antibiotics; antibiotics will not reduce pain for the child; recent study showed that 20 children would not to receive antibiotics for 5 to 7 days in order for ONE child to have some sort of pain relief.

Question 6

What is the CENTOR CRITERIA for tonsillopharyngitis?

Answer 6

1. fever > 38.5°C
2. cervical lymphadenopathy
3. tonsillar swelling / exudate
4. absence of cough

3 to 14 years of age (+1 point)
14 to 44 years of age (+0 points)
>45 years of age (-1 point)

SCORING SYSTEM
0 - 1 –> do NOT prescribe antibiotics
2 - 3 –> perform throat swab and RADT –> Abx if +ve
4 –> prescribe Abx empirically

Question 7

What are some RED FLAGS for a sore throat?

Answer 7

✔️ persistent high fever
✔️ non-responsive to antibiotics
✔️ sharp pain on swelling (suggestive of foreign body)
✔️ immunocompromised patient, DM or corticosteroid use (suggestive of oral thrust)
✔️ drooling + high fever (suggestive of epiglottitis in a child)
✔️ medication-induce agranulocytosis
✔️ marked swelling of quinsy

Question 8

Management of a sore throat?

Answer 8

Around 50% of cases of a sore throat are viral in origin; antibiotics will be of no help in alleviating pain or treating the condition.

Management should include:
✔️ adequate fluid intake (liquid drinks, icy poles etc)
✔️ analgesic mouth wash
✔️ antiseptic mouth wash / gargle
✔️ rest
✔️ antibiotics only if criteria is met (Centor Criteria)

Patient reassurance and education is key to appropriate antibiotic stewardship.

Question 9

What are the most common pathogens implicated in OTITIS EXTERNA?

Answer 9

✔️ Pseudomonas aeruginosa
✔️ S. aureus
✔️ E. coli
✔️ Klebsiella species
✔️ Aspergillus 
✔️ Candida

Question 10

Outline the management protocol for OTITIS EXTERNA.

Answer 10

AURAL TOILET
✔️ involves suction + dry mopping of the ear prior to use of topical antibiotics or ear wick

EAR WICK
✔️ ear wick should be inserted for up to 5 days; changed every 6 - 8 hours
✔️usually soaked in both topical antibiotic + analgesic

EAR DROPS
✔️ topical Kenocomb or Sofradex should be adminstered
✔️ advise against swimming or getting ear wet whilst showering

Question 11

What is the diagnostic criteria for acute bacterial rhino sinusitis?

Answer 11

At least TWO of the following four criteria:

1. facial fullness / pain / pressure
2. purulent nasal discharge
3. nasal obstruction
4. hyposomnia / ansomnia

Question 12

What is the management of acute bacterial rhinosinusiti ?

Answer 12

Amoxicillin PO for 5 days.

Question 13

Appropriate antibiotic management for sore throat (if Centor criteria met)?

Answer 13

Phenoxymethylpenicillin BD for 10 days

Question 14

Complications of GAS strep throat?

Answer 14

Non-suppurative complications:
✔️ ARF
✔️ RHD
✔️ PSGN

Suppurative complications:
✔️ Quinsy / peritonsillar absecess
✔️ acute otitis media

Question 15

Differential diagnosis for SORE THROAT?

Answer 15

VIRAL CAUSES - typically sore throat, nil fever, cough, hoarseness of the voice, coryzal symptoms
✔️ adenovirus
✔️ rhinovirus
✔️ RSV
✔️ influenza virus
✔️ parainfluenza virus
✔️ EBV (fever, painful cervical lymphadenopathy, viral pharyngitis)
✔️ CMV
✔️ HSV 

BACTERIAL CAUSES - typically high fever, absence of cough, malaise + lethargy, tonsillar exudate
✔️ Strep pyogenes (GAS)
✔️ S. pneumoniae 
✔️ S. aureus
✔️ Diphtheria
✔️ Haemophilis influenza B
✔️ Syphilis (rare)
✔️ N. gonorrhea (rare)

OTHER - more common in immunocompromised or diabetic patients
✔️ oral thrush
✔️ C. pneumoniae
✔️ M. pneumoniae