ENT Flashcards
What is epiglottitis?
What is the most common causative organism?
Inflammation & swelling of the epiglottis caused by infection; epiglottis can swell to point of completely obstructing the airway within hours hence it is a life threatening emergency.
Most common causative organism was typically was Haemophilus influenza type B however since vaccination Streptococcus species predominate. Incidence has decrease since introduction of HiB vaccine.
Why are children at higher risk of acute airway obstruction?
Children are at higher risk of acute airway obstruction because of their anatomy:
- Child’s epiglottis is much more floppy, broader, longer and angled more obliquely to the trachea
- larger tongue
- anteriorly-angled vocal cords
… mean children find it more difficult to move air past even a partial obstruction.
State some risk factors for epiglottitis
- Children not vaccinated against Haemophilus influenza
- Immunosupression
Describe the clinical features of epiglottitis
Rapid onset of symptoms <12hrs:
- Drooling
- Dyspnoea
- Stridor
- Sat in tripod position (sat leaning forward on outstretched arms with neck extended and tongue out)
- Muffled voice/”hot potato voice”
- High fever
- Sore throat
- Difficulty or pain swallowing
- Toxic/septic/unwell appearance
*Can remember by 4D’s: dyspnoea, dysphagia, drooling & dysphonia
State some differential diagnoses for epiglottitis
- Croup
- Inhaled foreign body
- Retropharyngeal abscess
- Tonsillitis
- Peritonsillar abscess
If a child is acutely unwell and epiglottitis is suspected investigations should not be performed; however, if you were to do investigations what investigations would you do?
Children with epiglottitis have high risk of obstructing their airway if agitated hence they shouldn’t be examined or undergo unnecessary observations or investigations. Investigations you might do when child more stable:
- Throat swabs (both bacterial & viral)
- Bloods: FBC, blood cultures, CRP
- Lateral neck x-ray: shows characteristic thumbprint sign due to swollen epiglottis. Also useful for excluding foreign body
- Diagnosis made by direct visualisation should only be done by senior staff who are able to intubate if necessary
Discuss the management of epiglottitis
Emergency situation!! Management is centred around ensuring airway is secure. Most pts don’t require intubation but need to be prepared to perform at any time.
- Do NOT distress child (as could cause closure of airway)
- Alert a senior paediatrician, anaesthetist, ICU and ENT as endotracheal intubation or emergency tracheostomy may be necessary
- Oxygen (if parent can hold mask near child’s face)
- Nebulised adrenaline (temporary relief of oedema)
- IV antibiotics (Ceftriaxone/cefotaxime)
- IV steroids
- IV intravenous fluids
Discuss the prognosis and potential complications of epiglottitis
Prognosis
- Most patients do not need intubating
- Most patients who are intubated can be extubated after a few days and make a full recovery
- However death may occur if not diagnosed and managed in time
Potential complications
- Epiglottic abscess (collection of pubs around epiglottis which can also threaten airway and is managed in same way as epiglottitis)
- Deep neck space infection (e.g. retropharyngeal abscess)
- Mediastinitis (rare)
- Sepsis
- Meningitis
-
Pneumonia (particularly after extubation)
*
Compare epiglottitis & croup
What is laryngomalacia?
Congenital abnormality of the larynx cartilage that predisposes to dynamic supraglottic collapse during the inspiratory phase of respiration; resulting in intermittent upper airway obstruction and inspiratory stridor as larynx cartilage flops across the airway during inspiration. Most common laryngeal abnormality and cause of stridor in neonates.
Is laryngomalacia a serious condition?
- Most cases are not associated with respiratory distress and are self limiting over several months
- However some severe cases may be life-threatening and require surgical intervention
Discuss the natural progression of laryngomalacia, including:
- When it first presents
- When symptoms peak
- When it usually resolves by
- Usually presents in first few weeks of life
- Symptoms peak at 6-8 months (when respiratory function increases before larynx increases in size)
- Usually resolves in first 2 years (remember serious forms may require surgical intervention as they are life-threatening)
State four structural abnormalities in laryngomalacia
- Short aryepiglottic folds (these pull on epiglottis and change its shape)
- Long, curled ‘omega shaped’ epiglottis
- Redundant arytenoid mucosa making arytenoids bulky and prone to collapsing into airway
- Tissue around supraglottic larynx has less tone
Discuss the typical presentation of laryngomalacia
- Inspiratory stridor
- Stridor is intermittent, worse when: feeding, upset, lying on back or during respiratory tract infections
- Normal cry
*Rarely causes complete airway obstruction or other complications such as respiratory distress, obstructive sleep apnoea, poor weight gain
State some differential diagnoses for laryngomalacia
- Vocal cord paralysis
- Subglottic stenosis
- Epiglottitis
- Croup
What is the key investigation for laryngomalacia?
First line= flexible laryngoscopy
If need to view subglottic region would do rigid larygnoscopy
Discuss the management of laryngomalacia; think about management of mild, severe and life-threatening cases
Mild cases
- 90% cases are mild and don’t require treatment
- Educate parents about progression (e.g. peak at 6 months, exacerbated by infections, resolved by 2yrs)
- GORD can exacerbate so may consider anti-reflux medications if GORD is present
Severe cases
- Surgery to change shape of larynx e.g. endoscopic aryepiglottoplasty
Life-threatening
- Keep child calm
- Involve senior paediatrician, anaesthetist, ENT, HDU/ICU
- Steps to help maintain own airway:
- Humidified oxygen
- Nebulised adrenaline
- Oral or IV dexamethasone (don’t cannulate if will cause distress)
- Heliox (helium & oxygen- helium helps oxygen flow through narrower spaces)
- If fail to maintain own airway will need ventilatory support (could try laryngeal mask, endotracheal intubation). *NOTE: tracheostomy is rarely required.
- Surgical intervention
What is obstructive sleep apnoea
Episodes of complete or partial airway obstruction of upper (in particular pharyngeal) airway during sleep. Present in 1-3% children.
State some risk factors for obstructive sleep apnoea in children
- Craniofacial abnormalities
- Low muscle tone
- Down’s syndrome
- Sickle cell anaemia
- Obesity
What is the peak age of incidence of OSA in children?
3-6yrs
State some symptoms & signs of OSA in children
- Snoring. gasping or choking while asleep
- Breathing through an open mouth
- Sleeping with hyperextended neck
- Restless sleep & periodic limb movements
- Night sweats (as consequence of laboured breathing)
- Secondary nocturnal enuresis
- Hypertension
- Wake up feeling tired +/- headache
- Poor school performance: lack of concentration
- Poor growth & weight
What investigation is used to diagnose OSA in children?
Polysomnography
Discuss the management of OSA in children
- First line= adenotonsillectomy (curative in about 80-90%)
- Second line (if above doesn’t work or child not suitable)= CPAP
- Adjuncts: Montelukast and/or intranasal budesonide (particularly useful if OSA worsened by allergy)
Also treat any modifiable conditions e.g. obesity, GORD. Avoidance of tobacco smoke.
If have craniofacial abnormalities may require maxiofacial surgery.
What is the most common cause of tonsillitis; viral or bacterial?
What is the peak ages of incidence?
- Viral is most common
- Most common causes of bacterial tonsillitis is group A Streptococcus (Streptococcus pyogenes). Others include: Streptococcus pneumoniae (2nd), H.influenza, S.aureus, Moraxella catarrhalis
Peak at 5-10yrs and again at 15-20yrs
Remind yourself of the structure of Waldeyer’s tonsillar ring and state which structure is most commonly infected in tonsillitis
Palatine are infected in tonsillitis
Describe clinical features of tonsillitis
- Fever
- Sore throat
- Odynophagia
- Erythematous, inflamed, enlarged tonsils +/- exudates
Presentation may be more non-specific in younger children:
- Headache
- Poor oral intake
- Vomiting
- Abdo pain
What must you always examine in child with suspected tonsillitis?
- Ears (otoscopy)
- Cervical lymphadenopathy
We can use either the Centor criteria or the FeverPAIN Score to help us determine the probability that tonsillitis is due to bacterial infection and so pt will benefit from abx; describe the Centor criteria
- Fever over 38 degrees
- Tonsillar exudates
- Absence of cough
- Tender anterior cervical lymphadenopathy
3 or more gives 40-60% probability of bacterial tonsillitis so appropriate to give abx
We can use either the Centor criteria or the FeverPAIN Score to help us determine the probability that tonsillitis is due to bacterial infection and so pt will benefit from abx; describe the FeverPAIN score
- Fever in past 24hrs
- Purulent tonsils
- Attended within 3 days of onset of symptoms
- Inflamed tonsils
- No cough or coryzal symptoms
Score of 2-3 gives 34-40% probability and score of 4-5 gives 62-65% probability of bacterial tonsillitis; hence if score 4 or more give abx
Discuss the management of tonsillitis
- Education that it is likely viral
- Self care: rest, plenty of fluids, paracetamol or/and ibruprofen for pain & fever
- Safety net: advise to return if no improvement in 3 days or fever >38.3 or if inadequate intake, breathing difficulties etc…
- Antibiotics: penicillin V for 10 days or clarithromycin if true penicillin allergy if bacterial (Centor =/>3, FeverPAIN =/>4) or if at risk of more serious infection e.g. very young, immunocompromised, significant co-morbidity, hx of rheumatic fever. May give delayed prescription.
- Consider admission if systemically unwell, dehydrated, stridor, resp distress, evidence of peritonsillar abscess or cellulitis
State some potential complications of tonsillitis
- Peritonsillar abscess (quinsy)
- Chronic tonsillitis
- Otitis media (infection spread to middle ear)
- Post-streptococcal glomerulonephritis
- Post-streptococcal reactive arthritis
- Scarlet fever
What is a peritonsillar abscess/quinsy?
What is most common causative organism? Any others?
Is it always preceded by tonsillitis?
- Abscess (collection of pus) in peri-tonsillar region
- Most common is Streptococcus pyogenes (group A Strep). Others: S.aureus, H.influenza
- Usually complication of untreated or partially treated tonsillitis but can arise without tonsillitis
What is otitis media?
How does the infection often occur/what does it follow?
Common causative bacteria?
- Infection of the middle ear
-
Commonly preceded by viral URT infection however most infections are due to bacteria, commonly:
- Streptococcus pneumonia
- Haemophilus influenza
- Moraxella catarrhalis
- Staphylococcus aureus
- ***NOTE: Streptococcus pneumoniae is also most common cause of rhino-sinusitis & second most common cause of bacterial tonsillitis*
- ***NOTE: thought that viral URTIs disturb nasopharyngeal microbiome allowing bacteria to infect middle ear via Eustachian tube*
Describe clinical features of quinsy
Similar symptoms to tonsillitis:
- Sore throat
- Odynophagia
- Fever
- Lymphadenopathy
- Referred ear pain
Additional symptoms that indicate quinsy:
- Trismus (difficulty opening mouth)
- Change in voice (hot potato voice)
- Reduced neck mobility
- Deviation of ulna to the unaffected side
- Swelling & erythema beside tonsils
Discuss the management of quinsy
Admit/refer to hospital under care of ENT team for:
- Needle aspiration or incision & drainage (under GA)
- IV antibiotics (e.g. co-amoxiclav but check local guidelines)
- Some ENT surgeons give dexamethasone
- May consider tonsillectomy to prevent recurrence
Quinsy can occur just as frequently in adolescents & young adults as it does in children; true or false?
True, unlike tonsillitis which is more common in children
What is the NICE guidance in regards to tonsillectomy’s/who do they suggest is offered tonsillectomy?
- 7 or more in 1yr
- 5 per year for 2 yrs
- 3 per year for 3 yrs
- Recurrent peritonsillar abscesses (2 episodes)
- Enlarged tonsils causing breathing difficulties (e.g. stridor, OSA) , swallowing difficulties or snoring
- Recurrent febrile convulsions secondary to episodes of tonsillitis
State some potential complications of tonsillectomy
- Risks of GA
- Pain (can last 2 weeks)
- Post-tonsillectomy bleeding/haemorrhage
- Damage to teeth
- Infection
Post-tonsillectomy bleeding is the main significant complication after tonsillectomy and it can occur in up to 5%. It requires urgent management as it can, although rare, be life threatening- usually due to aspiration of blood. Discuss the management of post-tonsillectomy bleeding
- Call ENT registrar early. Consider calling anaesthetist if severe bleeding or airway compromise as may need intubation.
- Sit child up and encourage them to spit blood rather than swallow
- Keep child calm & give analgesia if required
- Make child NBM
- Get IV access and do bloods: FBC, clotting screen, G&S, crossmatch
- IV fluids for maintenance & resuscitation as required
Child may need to go back to theatre. Two options to try before going back to theatre are:
- Hydrogen peroxide gargle (accelerates clotting. Blood catalyses its breakdown into O2 which then accelerates clotting as blood thinks in contact with fresh air)
- Adrenaline soaked swab applied topically (vasoconstriction)
Post-tonsillectomy bleeding could occur in first 24hrs or >24hr - 10 day period; what is common reason for each?
- First 24hrs: inadequete haemostasis
- 24hr- 10 days: most commonly due to infection
Describe typical presentation of otitis media
Infants may present with non-specific symptoms (irritability, poor feeding, fever, lethargy, vomiting).
Older children may present with:
- Otalgia
- Reduced hearing in affected ear
- Otorrhea
- Rubbing/tugging of ear
- URT infection symptoms (fever, cough, sore throat)
- Bulging, red, inflamed tympanic membrane (doughnut)
- Loss of light reflex
It is always worth examining the ears of an unwell child; how should you hold the ear when using otoscope?
Pull pinna gently up & backwards
Discuss the management of otitis media
Referral for Specialist Assessment & Admission
- <3 months with a temp >38 or aged 3-6months with a temp >39
- Consider specialist assessment if symptoms severe or diagnostic doubt
- Severe system infection
- Complications e.g. mastoiditis
General advice/management
- Educate: usually lasts 3/7 but can last up to 7/7
- Rest
- Fluids
- Simple analgesia for pain & fever
- Safety net
Antibiotics
-
First line= amoxicillin for 5/7. Erythromycin & clarithromycin are alternatives.
- Usually self-limiting therefore abx not required
- Consider prescribing at initial presentation if have significant co-morbidities, systemically unwell, immunocompromised, <2yrs with bilateral otitis media, otitis media with perforation and/or discharge in canal
- Give delayed prescription (collect in 3/7) if symptoms haven’t improved or worsened
State some potential complications of otitis media
Common sequale
- Otitis media with effusion
- Hearing loss (usually temporary)
- Perforated eardrum (leading to otorrhea. This may lead to CSOM)
- Recurrent infection
- Labyrinthitis
Complications
- Facial nerve paralysis
- Mastoiditis (rare)
- Abscess (rare)
- Meningitis
- Meningitis
What is CSOM?
- Chronic suppurative otitis media= chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges (otorrhoea) through a tympanic perforation
- WHO define it as >2 weeks of discharge, some experts say >6 weeks
- Managed by specialist; most likely to advise aural toileting, give topical abx (e.g. ciprofloxacin) and topical steroids
