ENT Flashcards
What is the most common cause of tonsillitis?
Viral infection
What is the most common cause of bacterial tonsillitis?
Group A streptococcus (strep pyogenes)
How can bacterial tonsillitis be treated?
Penicillin V
What is the most common cause of otitis media, rhinosinusitis and alternative bacterial cause of tonsillitis?
Streptococcus pneumoniae
What are some other common causes of tonsillitis?
Haemophilus influenzae
Morazella catarrhalis
Staphylococcus aureus
What is the throat made up of?
Oral cavity (teeth + tongue)
Pharynx
Tonsils
Larynx
What is the key anatomical difference in throat anatomy in childs compared to adults?
Narrowest point in children is the subglottis compared to the glottis in adults
What are the six areas of lympoid tissue in the throat?
Adenoid
Tubal tonsils
Palatine tonsils
Lingual tonsil
What tonsils are most commonly enlarged and infected in tonsillitis?
Palatine tonsials (at either side at back of throat)
What is Waldeyer’s tonsillar ring?
The ring of lymphoid tissue in the pharynx
What age range is most affected by tonsillitis?
5-10
How does tonsillitis usually present?
Fever
Sore throat
Painful swallowing
How may tonsillitis present in younger children?
Fever Poor oral intake Headache Vomiting Abdominal pain
What are exudates?
Small white patches of pus on the tonsil
What should you also assess when examining a child with tonsillitis/
The ears to visualise the tympanic membranes
Palpate for any cervical lymphadenopathy
What is the Centor criteria used to estimate?
The probability that tonsillitis is due to baacterial infection and will benefit from antibiotics
What are the features included in the centor criteria and how many ponts would qualify to offer antibiotics?
Fever >38
Tonsillar exudates
Absence of cough
Lymphadenopathy
(3 or more)
What are the FeverPAIN criteria when considering antibiotics in tonsillitis?
Fever Purulence Attended within 3 days of onset of symptoms Inflamed tonsils No cough or coryza
What should be excluded when diagnosing tonsillitis?
Meningitis
Epiglottitis
Peritonsillar abscess
Calculate centor/ feverPAIN score
How is viral tonsillitis managed?
Give safety net advice (if not settled after 3 days or fever above 38.3)
Advise simple analgesia with paracetamol and ibuprofen
How is bacterial tonsillitis managed?
Penicillin V 10- day course
Clarithromycin= second choice
(can give delayed prescription if needed)
What are the complications of tonsillitis?
Chronic tonsillitis Peritonsillar abscess Otitis media Scarlet fever Rheumatic fever Post-strep glomerulonephritis Post-strep reactive arthritis
What is a quinsy?
Peritonsillar abscess
What causes a quinsy?
When there is a bacterial infection with trapped pus that forms an abscess on the tonsils
When does a quinsy commonly occur?
In untreated or partially treated tonsillitis
Are tonsillitis and quincies more common in children or adults?
Tonsillitis much more common in children
Quinsy just as common in children as adults
How does quinsy present?
Similar to tonsilitis May also have: Trismus Change in voice (hot potato voice) Swelling/ erythema in area besides tonsils
What is trismus?
When a patient is unable to open their mouth
What is the most common cause of a quinsy?
Strep. pygones (group A)
Staph aureus
Haemophilus influenxae
How is a quinsy managed?
Incision and drainage of abscess under general anaesthetic
Broad spectrum antibiotics
What are the criteria for tonsillectomy?
7 or more episodes of tonsillitis in 1 year
5 per year for 2 years
3 per year for 3 years
Recurrent tonsilar abscesses
Tonsils causing difficulty breathing, swallowing or snoring
What are the complications of a tonsillectomy?
Pain/ sore throat for up to 2 weeks after Damage to teeth Infection Post-tonsillectomy bleeding Risks of GA
What is the most significant complication of tonsillectomy?
Post tonsillectomy bleeding which can happen up to 2 weeks after operation
How is post-tonsillectomy bleeding managed?
Called ENT registrar IV access Keep calm Analgesia Sit them up and get the to spit instead of swallow blood IV fluids May need intubation Theatre
What makes up the external ear?
Auricle (/pinna)
External acoustic meatus
What is the auricle made of and what is the exception?
Cartilage
Lobule is not supported by cartilage
What are the different components of the auricle?
Helix Antihelix Superior and inferior crus Tragus Antitragus Concha Lobule
What is the action of the concha?
Directs sound into the external acoustic meatus
Where does the external acoustic meatus begin and end?
Extends from the deep part of the concha to the tympanic membrane
What are the walls of the external acoustic meatus composed of?
External 1/3= cartilage
Internal 2/3= temporal bone
What is the tympanic membrane made of?
Connective tissue structure covered with skin on outside and mucous membrane on inside
What are the margins of the middle ear?
Tympanic membrane to lateral wall of inner ear
What are the two parts of the middle ear?
Tympanic membrane
Epitympanic recess
What is the tympanic membrane and what does it contain?
The space behind the tympanic membrane containing the auditory ossicles
What are the auditory ossicles?
The three small bones
What is the epitympanic recess?
The space above the tympanic cavity
What are the bones of the middle ear?
Malleus
Incus
Stapes
What is the action of the auditory ossicles?
Transfer sound vibrations from the tympanic membrane to the oval window of the internal ear
What is the eustachian tube?
The cartilaginous and bony tube that connects the middle ear to the nasopharynx
Where is the inner ear located?
In the temporal bone
What does the innerear contain?
The vestibulocochlear organs
What are the two main functions of the inner ear?
Convert mechanical signals into electrical signals
Maintain balance
How does the inner ear maintain balance?
Detects position and motion
What are the margins of the inner ear?
Middle ear to internal acoustic meatus
What are the two main components of the inner ear?
Bony labyrinth
Membranous labyrinth
What is the bony labyrinth?
Series of bony cavities within the petrous temporal bone
What is the bony labyrinth composed of?
Cochlea, vestibule and three semi-circular canals
Where is the membranous labyrinth and what is it composed of?
Lies within bony labyrinth and consists of cochlear duct, semi-circular ducts, urticle and saccule
Filled with fluid (endolymph)
What are the two openings in the inner ear?
Oval window
Round window
Which part of the inner ear is responsible for converting sound vibrations into electrical signals?
Cochlea
Which part of the inner ear is responsible to balance?
Saccule and urticle
What is otitis media?
Infection of the middle ear
Where is the most common site of ear infection in children?
Middle ear
How does the middle ear get infected?
Bacteria enter the ear from the back of the throat via the eustachian tube
What is bacterial infection of the ear often preceded by?
Viral upper respiratory tract infection
What are the most common bacterial causes of otitis media?
Strep pneumonia*
Haem. influenzae
Moraxella catarrhalis
Staph aureus
How does otitis media typically present?
Ear pain
Reduced hearing
Upper airway infection symptoms
What symptoms may occur if the infection affects the vestibular system?
Balance issues
Vertigo
When would you get discharge from the ear?
IF the tympanic membrane is perforated
How may otitis media present in young children and infants?
Non-specific Fever Vomiting Irritability Lethargy Poor feeding
How should you examine a child with suspected otitis media?
Examine both ears and throat
Use otoscope to visualise tympanic membrane
What should the tympanic membrane look like in a healthy child?
‘pearly-grey’, translucent and shiny
How should otitis media be managed?
Simple analgesia
Most cases resolve within 3 days without antibiotics
What are the three options regarding prescribing antibiotics to patients with otitis media?
- Immediate if severe, immunocompromised or multiple co-morbidities
- Delayed prescription for if it doesn’t clear
- No antibiotics
What is the first line choice of antibiotic with otitis media?
Amoxicillin for 5 days
What are the complications of otitis media?
Glue ear Hearing loss Perforated eardrum Recurrent infection Mastoiditis Abscess
What is glue ear?
Otitis media with effusion
What happens in glue ear?
The middle ear becomes full of fluid, causing a loss of hearing in that ear
What causes glue ear?
When the eustachian tube becomes blocked, middle ear secretions build up in the middle ear space
What is the main symptom of glue ear?
Reduction of hearing in that ear
What is the main complication of glue ear?
Infection (Otitis media)
What will otoscopy show with glue ear?
Dull tympanic membrane with air bubble or visible fluid level
(may look normal)
How is glue ear diagnosis confirmed?
Refer for audiometry to establish extent of hearing loss
How is glue ear treated?
Conservatively
How long does it usually take glue ear to clear up?
3 months
How may children with co-morbidities affecting the ear be treated for glue ear?
Grommets
What are grommets?
Tiny tubes inserted into the tympanic membrane, which allow fluid from the middle ear to drain through the tympanic membrane to the ear canal
How long do grommets last?
Around a year
What are the 3 categories of causes of hearing loss?
Congenital
Perinatal
Acquired
What are the most common congenital causes of hearing loss?
Maternal infection
Genetic
Syndromes (e.g. Down’s)
What are the most common perinatal causes of hearing loss?
Prematurity
Hypoxia during/ after birth
What are the most common causes of acquired hearing loss?
Jaundice
Meningitis/ encephalitis
Otitis media/ glue ear
Chemotherapy
How is congenital hearing problems usually picked up?
Newborn hearing screening programme
How may hearing problems present?
At screening
Parental concerns about hearing or behavioural changes (poor speech and language, school behaviour, ignoring)
How are young children tested for hearing problems?
Special equipment used to deliver sound to each eardrum individually and check for basic response
How are older children tested for hearing problems?
Using headphones and specific tones and volumes
What are the results of audiometry recorded on?
An audiogram
What are audiograms?
Charts that document the volume at which patients can hear different tones
What is on the x axis of an audiogram?
Frequency (in hertz) from low to high pitched
What is on the y-axis of an audiogram?
Volume (in decibels) from loud to quiet
What two things are tested separately when assessing hearing?
Bone and air conduction
What should readings be between if a patient has normal hearing?
0-20dB
What is sensorineural hearing loss?
When the route cause is due to the inner ear (cochlea or nerve)
What will be found in audiography or sensorineural hearing loss?
Both bone and air conduction readings will be >20dB
What is conductive hearing loss?
When there is a problem transferring sound waves somewhere along the pathway
What will be found on audiography of conductive hearing loss?
Normal bone conduction readings (0-20) but air conduction readings >20dB
What will be found on audiography of mixed hearing loss?
Both air and bone conduction readings >20dB, but with a difference of >15 between the two
How is hearing loss managed?
MDT: SALT Educational psychology ENT specialist Hearing aids Sign language
What are nosebleeds also known as?
Epistaxis
Where do nosebleeds originate from?
Kiesselbach’s plexus (Little’s area)
What is Kiesselbach’s plexus?
Area of the nasal mucosa at the front of the nasal cavity that contains a lot of blood vessels
What may trigger nosebleeds?
Nose picking Colds Vigorous blowing Trauma Changes in weather
Are nosebleeds usually uni or bilateral?
Unilateral
How should you advise patients with nosebleeds to position themselves?
Sit up and tilt head forewards to avoid blocking airway
Squeeze soft part of nostrils for 15 minutes
Spit any blood
What should be done if epistaxis does not stop after 10-15 minutes?
Nasal packing with nasal tampons/ inflatable packs
Nasal cautery using a silver nitrate stick
What kind of condition is cleft lip?
Congenital
What is cleft palate?
When there is a defect in the hard or soft palate leaving an opening between the mouth and nasal cavity
Do cleft lip and palate always occur together?
No, they can occur on their own
What are the complications of cleft lip/ palate?
Problems feeding & swallowing
Speech issues
Psycho-social implications
How is cleft lip/ palate managed?
Local cleft lip services MDT:
Specialist nurses, surgeons, dentists, SALT, psychologitsts
What is the first priority in treated cleft lip/ palate?
Ensure baby can eat/ drink
What is the definitive treatment of cleft lip/ palate?
Surgically correct
At what age is cleft lip surgery usually performed?
3 months
At what age is cleft palate surgery usually performed?
6-12 months
What is ankyloglossia?
Tongue tie
What is tongue tie?
When a baby is born with a short and tight lingual frenulum
What is the lingual frenulum?
The attachment of the tongue to the floor of the mouth
What are the complications of tongue tie?
Difficulties extending tongue and latching onto breast
How does tongue tie usually present?
Poor feeding
Newborn check
How is tongue tie managed?
Mild= monitored
If affects feeding= frenotomy
What is a cystic hygroma?
Malformation of the lymphatic system, resulting in a cyst filled with lymphatic fluid
Where is a cystic hygroma usually located?
Posterior triangle on left side of neck
What is the cause of cystic hygroma?
Congenital abnormality
When is cystic hygroma usually picked up?
Antenatal scans
Routine baby checks
Incidental finding
What are the key features of cystic hygromas?
Large, soft, non-tender, transilluminate lump in neck or armpit
What are the complications of cystic hygroma?
Can interfere with feeding, swallowing or breathing
Can become infected
Can be haemorrhage into cyst
What are the different management options for cystic hygromas?
Watch and wait
Aspiration
Surgical removal
Sclerotherapy
Where does the thyroid gland begin a the start of fetal development?
At the base of the tongue
How does the thyroid gland get to its final position?
It descends
What is the thyroglossal duct?
The track left behind as the thyroid gland descends down the neck
What is a thyroglossal cyst?
When a part of the thyroglossal duct persists and gives rise to a fluid filled cyst
What is a key differential diagnosis of a thyroglossal cyst?
Ectopic thyroid tissue
What is the main complication of thyroglossal cyst?
Infection
What are the features of thyroglossal cysts?
Mobile Non-tender Soft Fluctuant On midline of neck *Move up and down with movement of tongue
How are thyroglossal cysts diagnosed?
USS
CT scan
How are Thyroglossal cysts treated?
Surgically removed
What is a branchial cyst?
Congenital abnormality arising when second branchial cleft fails to form properly
How do branchial cysts form?
When the second branchial cleft fails to develop, it leaves a space surrounded by epithelial tissue which can fill with fluid
Where are branchial cysts found?
Between angle of jaw and sternocleidomastoid muscle in anterior triangle of neck
What are the features of branchial cysts?
Round
Soft
Non-tender
Anterior to sternocleidoastoid
After what age to branchial cysts usually present?
10
What is a sinus?
A blind ending pouch
What is a fistula?
Abnormal connection between two epithelial surfaces
What is a branchial cleft sinus?
When the branchial cyst is connected via a tract to the outer skin surface
What is a branchial pouch sinus?
When the branchial cyst is connected via a tract to the oropharynx
What is a branchial fistula?
When there is a tract connecting the oropharynx to the outer skin surface via the branchial cyst
How are branchial cysts managed?
Conservative
If causing issues, surgical excision
