ENT Flashcards
What is tonsilitis?
Inflammation in the tonsils
What commonly causes tonsillitis?
Most commonly viral.
Bacterial causes
- Group A Strep (pyogenes)
- streptococcus pneumoniae
- haem influenza
How is tonsillitis managed?
If viral - self resolving. Safety net.
Bacterial (fever pain score > 4) - give penicillin V (phenoxymethylpenicillin) for 10 days (or clarithromycin in allergy)
How does tonsillitis present?
- Fever
- Sore throat
- swollen erythematous tonsils with white exudate
- swollen lymph nodes - cervical lymphadenopathy
- headache
- vomiting
What is the centor criteria for?
A score of 3 or more is suggestive of bacterial tonsillitis - can offer antibiotics.
- fever over 38
- tonsillar exudates
- absence of cough
- tender anterior lymphadenopathy
What is the FeverPAIN Score?
Scoring to determine probability that tonsilitis is bacterial.
- Fever in last 24 hrs
- Pus on tonsils
- Attended within 3 days of onset of symptoms
- Inflamed tonsils
- No cough
What are some complications of tonsillitis?
- chronic tonsillitis
- peritonsillar abscess - quinsy
- otitis media
- scarlet fever
- rheumatic fever
- post streptococcal glomerulonephritis
- post streptococcal reactive arthritis
What is quinsy?
Peritonsillar abscess
How does quinsy present?
- similarly to tonsillitis - sore throat, fever, lymphadenopathy
- trismus - unable to open their mouth
- change in voice - due to pharyngeal swelling
- swelling and erythema around the enlarged tonsils
What is the management for quinsy?
- refer to ENT for incision and drainage (under general)
- antibiotics
- steroids - dexamethasone - to settle inflammation
What are the indications for tonsillectomy?
Repeated episodes of tonsillitis
- 7 or more in 1 year
- 5 per year for 2 years
- 3 per year for 3 years
- recurrent tonsillar abscesses (>2)
- enlarged tonsils causing obstruction
What are some of the potential complications of tonsillectomy?
- pain (up to 2 weeks)
- damage to teeth
- infection
- bleeding ( if severe can be life threatening due to aspiration of blood)
- risks of general anaesthetic
How is post tonsillectomy bleeding managed?
- call ENT registar
- IV access - bloods inc. clotting, group + save and crossmatch
- analgesia
- sit up and encourage to spit out blood
- nil by mouth
- IV fluids
- if airway compromise - maintain / intubate
If not severe can give hydrogen peroxide gargle or adrenalin soaked swab to stop the bleeding.
If severe = go to theatre
What is otitis media?
Infection in the middle ear (between the tympanic membrane and inner ear)
What most commonly causes otitis media?
- often a prior viral URTI.
- bacteria can travel from the back of the throat through the eustachian tube to the middle ear
Bacteria
- streptococcus pneumoniae
- haemophilus influenza
- moraxella catarrhalis
- staph aureus
How does otitis media present?
- ear pain
- reduced hearing (unilateral)
- symptoms of URTI - cough, fever, sore throat, aches, irritablity
If spreads to vestibular system
- balance problems and vertigo
if tympanic membrane perforates - discharge from ear.
How is otitis media diagnosed?
Examination of both ears using a otoscope (pull ear up and back).
- the tympanic membrane of the affected ear will look bulging, red and inflamed. Perforation = discharge in canal.
How is mild otitis media managed?
- simple analgesia for fever and pain
- can prescribe a delayed prescription of antibiotics (amoxicillin for 5 days) for if symptoms have not improved after 3 days.
When may antibiotics be immediately prescribed for otitis media?
- immunocompromised / co-morbidities
- < 2 years old
- otorrhoea - ear discharge
What are the main complications of otitis media?
- otitis media with effusion (glue ear)
- hearing loss - normally temporary
- perforated eardrum
- recurrent infection
- Mastoiditis (rare)
- abscess (rare)
What is otitis media with effusion?
When the middle ear becomes filled with fluid causing a unilateral conductive hearing loss.
What causes otitis media with effusion?
Blockage of the eustachian tube meaning fluid builds up in the middle ear
How does otitis media with effusion present?
Reduced hearing
What is the main complication of otitis media with effusion?
Infection (otitis media)
What is seen on otoscopy in otitis media with effusion?
- dull tympanic membrane
- air bubbles
- visible fluid level
How is otitis media with effusion managed?
- do audiometry to help diagnosis
- normally resolves without treatment in 3 mnths
- if not can give grommets (small tubes inserted into the tympanic membrane that allows fluid to drain)
What is epistaxis?
Nosebleeds
Where is the most likely source of nosebleeds?
Kiesselbach’s plexus in Littles area (anterior)
More severe nosebleeds that don’t stop may be from the sphenopalatine artery (posterior)
What can trigger nosebleeds?
- nose picking
- colds
- trauma
- vigorous nose blowing
What can bilateral nosebleed indicate?
Posterior bleeding.
How should nosebleeds be managed?
Advise to
- sit up and tilt head forwards
- squeeze soft past of the nose for 10-15 mins
- spit out any blood in the mouth (rather than swallowing)
If it doesn’t stop after 10-15 mins
- anterior nasal packing
- nasal cautery - using silver nitrate
- consider meds such as tranexamic acid to stop bleeding.
- after can prescribe chlorhexidine and neomycin to reduce crusting, inflammation and infection.
What is cleft lip?
Congenital condition where there is a split or open section of the upper lip that can extend as high as the nose
What is cleft lip?
Congenital condition where there is a split or open section of the upper lip that can extend as high as the nose
What is cleft palate?
Congenital defect in the hard or soft palate and the roof of the mouth. Leaves and opening between the mouth and nasal cavity. (can occur alongside cleft lip)
What are some of the complications of a cleft lip or palate?
- difficulty feeding and swallowing
- difficult in speech
- psycho-social implications
- more prone to hearing problems, ear infections and otitis media with effusion
How are cleft lips and palates managed?
Specialised services
- nurses - . ensure nutrition - e.g. through special shaped bottles
- plastic, maxillofacial and ENT surgeons
- dentists
- speech and language therapists
Definitive treatment = surgery between 6 and 12 months.
What is ankyloglossia?
Tongue tie - when a baby is born with a short and tight lingual frenulum. Means they can’t properly extend their tongue
How is tongue tie normally picked up?
Due to poor feeding - as it makes it more difficult for them to latch onto the breast
How is tongue tie managed?
If mild - doesn’t require any managedment.
Frenotomy - cutting of the frenulum - normally can be done on the ward without any anaesthetic.
What are complications of frenotomies?
Very rare
- excessive bleeding
- scar formation
- infection
What is a cystic hygroma?
Malformation of the lymphatic system resulting in a fluid filled cyst -most commonly in the neck (left posterior triangle) or the armpits
What are the key features of a cystic hygroma?
- lump in the neck or armpit present from birth
- can be very large
- soft
- non tender
- transilluminates
What are the complications of a cystic hygoma?
Depending on the size and location - can interfere with
- feeding
- swallowing
- breathing
Can become infection.
Can haemorrhage into the cyst.
How are cystic hygomas managed?
If small can watch and wait - can regress but do not resolve itself.
Other options
- aspiration (temporary improvement)
- surgical removal
- sclerotherapy
How do thyroglossal cysts form?
When the thyroid gland descends from the base of the tongue to the throat in fetal development, it leaves behind a tract called the thyroglossal duct. This normally disappears. If it is left behind, it can give rise to a fluid filled cyst.
What is the main complication of a thyroglossal cyst?
infection
Describe thyroglossal cysts
- midline lump
- mobile
- non tender
- soft
- fluctuant
- move up and down with movements of the tongue
How are thyroglossal cysts investigated?
Ultrasound or CT scans
How are thyroglossal cysts managed?
Normally surgically removed.
(however can recur after surgery unless the full thyroglossal duct is removed)
How does a branchial cyst form?
Arises from the second branchial cleft if it fails to form properly during development. This leaves and empty space in the lateral neck where fluid can fill
Describe branchial cysts
- swelling between the angle of the jaw and the SCM in the anterior triangle of the neck
- round
- soft
- tend to present after 10 y.o or if it becomes infected
How are branchial cysts managed?
Often conservative management / do nothing.
If recurrent infections or other (e.g. cosmetic) issues - can do a surgical excision
Useful links for neck lumps
https://www1.racgp.org.au/ajgp/2019/may/paediatric-neck-lumps
What are some causes of paediatric neck lumps?
- thyroglossal cyst (midline - moves with tongue)
- branchial cyst - anterior to SCM
- dermoid cyst
- goitre
- sialadenitis (enlargement of one of the salivary glands)
- lymphadenitis
- reactive lymphadenopathy
- malignant lymphadenopathy
- salivary gland tumour
- benign connective tissue tumour
