ENT Flashcards
What is tonsillitis?
How does it present?
How is it managed?
(RECAP)
Inflammation of commonly the palatine tonsils.
Viral causes usually, but can be bacterial; commonly strep.pyogenes, but also consider strep.pneumonia.
Presents with fever, sore throat, painful swallowing, lymphadenopathy. Younger patients; poor feeding, fever, headache, vomiting, poor oral intake.
Management:
Advice supportive management i.e. encourage fluids, oral intake, analgesia etc. If the pain does not resolve in 3 days or gets worse return for either Abx or alternative diagnosis.
Can prescribe Abx if FeverPAIN score ≥ 4 or Centor score ≥ 3. Give Abx if immunocompromised, very young or co-morbidities.
Also can give delayed prescription of Abx- for patients to take if worsens, or not resolved within 3 days.
Abx- 10 day course of phenoxymethylpenicillin. If allergic- clarithromycin.
Admission if:
Immunocompromised, severely unwell, dehydration, stridor, respiratory distress, signs of quinsy or cellulitis.
What is the Centor score?
What is the FeverPAIN score?
(RECAP)
To determine if tonsillitis is of bacterial cause, so as to prescribe Abx.
CENTOR: Lymphadenopathy Absence of cough Exudates Fever>38 degrees
FeverPAIN Fever >38 degrees Pus on tonsils Attended within 3 days of symptoms Inflamed tonsils No cough/coryza
What are the complications of tonsillitis?
RECAP
Quinsy Scarlet fever Post-strep glomerulonephritis Post-strep reactive arthritis Chronic tonsillitis
What is Quinsy?
How does it present?
How is it managed?
(RECAP)
Peritonsillar abscess, which can occur as a result of untreated/partially treated tonsillitis or independent of tonsillitis.
More common in teenagers and adults, but can occur in children.
Bacterial cause- usually Strep.pyogenes, but also Staph.aureus and H.influenza.
Presents with: Fever Sore throat Difficulty swallowing Referred ear pain Neck pain Trismus- inability to open mouth Hot potato voice Swelling/erythema besides the tonsils
Management:
ENT referral for surgical incision and drainage.
Give co-amoxiclav before and after the surgery.
Can give dexamethasone to reduce swelling.
When is a tonsillectomy performed?
What are the associated complications?
Day case surgery
Tonsillectomy criteria:
Tonsillitis for ≥7 in one year, ≥5 each year for 2 years or ≥3 each year for 3 years.
2 episodes of Quinsy
Enlarged tonsils causing difficulty breathing, swallowing or snoring.
Complications: Pain (sore throat for 2wks) Infection Damage to teeth Risk of GA Post-tonsillectomy bleeding- can occur within 2wks post op.
Post tonsillectomy bleeding is an emergency: Call ENT surgeon IV access and take FBC, G+S, crossmatch Give fluids Encourage child to spit any blood Give analgesia Keep child nil by mouth.
Before considering surgery, for minor bleeds try topical adrenaline (soaked in a swab) or hydrogen peroxide gargle.
What is otitis media?
How does it present?
(RECAP)
Infection of the middle ear, commonly a bacterial infection secondary to a viral URTI (commonly Strep.pneumoniae)
Presents with otalgia, reduced hearing and coryzal symptoms. In younger infants; poor feeding, irritability, vomiting, fever etc.
If inner ear affected will get vertigo, if TM perforation will get otalgia.
Should always examine the throat and ear. TM red and bulging, may be perforated.
How is otitis media managed?
What are the complcaitions?
(RECAP)
Management:
No Abx- Supportive management should resolve the otitis media within 3 days.
Abx- if systemically unwell,, immunocompromised, <2yrs with bilateral otitis media, children with otorrhea.
Delayed Abx- To be used if symptoms persists for >3days or get worse.
Admit <3 months if fever >38 degrees, 3-6 months if fever >39 degrees.
Abx- 5 day course of amoxicillin. If allergic then clarithromycin.
Complications: TM perforation Hearing loss (temporary) Recurrent infection Mastoiditis Abscess
What is otitis media with effusion?
How is it managed?
(RECAP)
Dysfunctional Eustachian tube- can’t drain the middle ear. Therefore build up of fluid in that ear leads to hearing loss of that ear.
Retracted, dull TM.
Manage conservatively; will self resolve within 3 months.
Can insert grommets which will fall out within a year.
Complications: Otitis media
What are the causes of hearing loss in children?
Can be congenital or acquired: Congenital: Maternal rubella/cytomegalovirus Genetic deafness (autosomal recessive, autosomal dominant) Associated diseases i.e Down's syndrome
Perinatal:
Hypoxia during birth
Prematurity
After birth: Jaundice Otitis media/ Glue ear Chemotherapy Meningitis/Encephalitis
How is hearing loss in children investigated?
How is it managed?
New-born hearing screening programme (NHSP)- Accurate in looking at response of TM to different dB and Hz of sound.
If not diagnosed on NHSP suspect if child does not respond to instruction, easily frustrated, poor language development, poor school performance.
If >3yrs old conduct audiometry- Looking at the minimum dB needed to hear a specific frequency. (CHL and SNHL) Normal hearing will have between 0-20dB.
If SNHL- both air and bone conduction are >20dB (so plotted below 20dB line on the chart)
If CHL- bone conduction 0-20dB (normal), but air conduction >20dB (so plotted below 20dB on the chart)
If mixed- both air and bone conduction would be >20dB but BC>AC by 15dB.
Management involves MDT approach: ENT SALT Educational psychology Sign Language Hearing aids where appropriate
How do nosebleeds present?
How are they managed?
(RECAP)
Due to trauma to Little’s area usually, i.e. picking the nose, harsh blowing, change in weather etc.
Often normal healthy child, with unilateral bleeding 9bilateral can indicate posterior nose bleed), can vomit blood if they have swallowed it during the bleed.
Self resolve
Tilt head forward and pinch soft part of nose for 10-15 minutes. Spit out any blood instead of swallowing.
Admit if not resolved after 10-15 mins, severe nose bleed, bilateral or patient unstable.
-Nasal packing with nasal tampons
-Nasal silver nitrate cautery.
then prescribe course of 10 days QDS naseptin to reduce crusting, infection and inflammation. Contraindicated in peanut and soy allergy.
If recurrent investigate for clotting disorders/thrombocytopenias.
What are cleft lip and palate?
How does it present?
Cleft lip- Split/open section of the upper lip which can extend to the nose.
Cleft palate- defect in either the soft or hard palate which leaves an opening between the mouth and the nasal cavity.
These can exist on their own or together.
Occurs spontaneously, although having a family member can slightly increase the likelihood.
This can lead to problems with feeding, swallowing, speech, psycho-social aspect (can be difficult for mother to bond with baby), prone to hearing problems and ear infections.
How is cleft lip and palate managed?
MDT approach:
Corrective surgery (plastic, maxillofacial and ENT surgeons)- Lip at 3 months, Palate at 6-12 months
SALT
Psychologist
GP
Dentists
Specialist nurses- first priority is to ensure baby can eat and drink; can give specialised bottles or teats to aid with this.
What is tongue tie?
How is it managed?
Short and tight lingual frenulum- attaches tongue to the base of the mouth.
Present with poor feeding or milder cases can be picked up on new-born baby checks.
Mild cases are usually just monitored.
When feeding is affected- expert clinician to perform frenotomy. This is done in clinic/on ward without anaesthetic and rarely has complications (XS bleeding, infection, scarring etc)
What is a cystic hygroma?
What are the features?
How is it managed?
Benign condition. Often located on left posterior triangle of the neck.
Malformation of the lymphatic system giving rise to a cyst full of lymphatic fluid
Is soft, non-tender, mobile and trans illuminates.
Can affect feeding, swallowing, breathing and may get infected- red hot and tender. Can also get haemorrhage into the cyst.
Management:
Often watch and wait, may regress but not likely.
Aspiration (temporary improvement), sclerotherapy or surgical removal are available treatment options.
