ENT Flashcards
What is tonsillitis?
Inflammation of the tonsils
Most common cause of tonsillitis?
Viral tonsillitis most common
If bacterial, most common is group A streptococcus - Streptococcus pyogenes
Most common alternative bacterial cause of tonsillitis Streptococcus pneumoniae
Other bacterial causes:
Haemophilus influenzae
Morazella catarrhalis
Staphylococcus aureus
What is Waldeyer’s Tonsillar Ring?
Ring of lymphoid tissue in the pharynx, six areas of lymphoid tissue, making up:
Adenoid
Tubal tonsils
Palatine tonsils
Lingual tonsil
Peak ages of presentation of tonsilitis?
5 to 10
15 to 20
Which tonsils are most commonly involved in tonsilitis?
The palatine tonsils are the ones typically infected and enlarged in tonsillitis. These are the tonsils at either side at the back of the throat.
Clinical presentation of tonsilitis?
FEVER
SORE THROAT
PAINFUL SWALLOW
Tonsillitis can present with non-specific symptoms, particularly in younger children. They may present with only a fever, poor oral intake, headache, vomiting or even abdominal pain.
Examination of the throat will reveal red, inflamed and enlarged tonsils, with or without exudates. Exudates are small white patches of pus on the tonsils.
What should be examined in suspected tonsilitis asides from the throat?
Always examine the ears (otoscopy) to visualising the tympanic membranes and palpate for any cervical lymphadenopathy when assessing a child with suspected tonsillitis.
What features score points under the Centor Criteria?
Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)
What features score points on the FeverPAIN Score?
Fever during previous 24 hours
P – Purulence (pus on tonsils)
A – Attended within 3 days of the onset of symptoms
I – Inflamed tonsils (severely inflamed)
N – No cough or coryza
Significance of FeverPAIN score
A score of 2 – 3 gives a 34 – 40% probability and 4 – 5 gives a 62 – 65% probability of bacterial tonsilitis
Significance of Centor criteria
A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics.
Serious pathology to rule out in ?tonsilitis
meningitis
epiglottitis
peritonsillar abscess
Advice to parents of children with likely viral tonsilitis?
Advise simple analgesia with paracetamol and ibuprofen to control pain and fever.
NICE clinical knowledge summaries suggest advising patients to return if the pain has not settled after 3 days or the fever rises above 38.3ºC. If this occurs you can start antibiotics or consider an alternative diagnosis.
Considering antibiotics?
Consider prescribing antibiotics if the Centor score is ≥ 3 or the FeverPAIN score is ≥ 4.
Also consider antibiotics if they are at risk of more serious infections, for example young infants, immunocompromised patients or those with significant co-morbidity, or there is a history of rheumatic fever.
Delayed prescriptions can be considered. This involves educating patients or parents about the likely viral nature of the sore throat, and providing a prescription that is to be collected only in the event that the symptoms do not improve or worsen in the next 2 – 3 days.
When should admission be considered for children with tonsilitis?
Consider admission if the patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or evidence of a peritonsillar abscess or cellulitis.
Antibiotic therapy in bacterial tonsilitis
Penicillin V (also called phenoxymethylpenicillin) for a 10 day course is typically first line
Clarithromycin is the first line choice in true penicillin allergy.
Potential complications of tonsilitis?
Chronic tonsillitis
Peritonsillar abscess, also known as quinsy
Otitis media if the infection spreads to the inner ear
Scarlet fever
Rheumatic fever
Post-streptococcal glomerulonephritis
Post-streptococcal reactive arthritis
How is the treatment of children with OSAS different to that of adults?
Surgery can be completely curative
Ménière’s disease management
Avoidance of stressors
Betahistine
Diuretic therapy
Grommet
Hearing aid
Prochlorperazine (buccal or IM)
Intra-tympanic gentamicin/steroid
Quinsy signs
The uvula deviated AWAY from the site of infection
A unilaterally enlarged tonsil, with or without exudate
A unilateral peritonsillar swelling with mucosal cellulitis
What is quinsy?
Quinsy is the common name for a peritonsillar abscess.
Peritonsillar abscess arises when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils.
Peritonsillar abscesses are usually a complication of untreated or partially treated tonsillitis, although it can arise without tonsillitis.
Peritonsilitis vs tonsilitis occurrence
Quinsy can occur just as frequently in teenagers and young adults as it does in children, unlike tonsillitis which is much more common in children.
Presentation of quinsy
Patients present with similar symptoms to tonsillitis:
Sore throat
Painful swallowing
Fever
Neck pain
Referred ear pain
Swollen tender lymph nodes
Additional symptoms that can indicate a peritonsillar abscess include:
Trismus, which refers to when the patient is unable to open their mouth
Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice”
Swelling and erythema in the area beside the tonsils on examination
What organism usually causes quinsy?
Quinsy is usually due to a bacterial infection. The most common organism is streptococcus pyogenes (group A strep), but it is also commonly caused by staphylococcus aureus and haemophilus influenzae.
Management of quinsy
incision and drainage
A broad spectrum antibiotic such as co-amoxiclav would be an appropriate choice to cover the common causes, but local guidelines will guide antibiotic choice according to local bacterial resistance.
Some ENT surgeons give steroids (i.e. dexamethasone) to settle inflammation and help recovery, although this is not universal.
What is a tonsillectomy and why is it performed?
Tonsillectomy is the name for the surgical removal of the tonsils. Removing the tonsils prevents further episodes of tonsillitis, although patients can still get a sore throat.
7 or more in 1 year
5 per year for 2 years
3 per year for 3 years
Other indications are:
Recurrent tonsillar abscesses (2 episodes)
Enlarged tonsils causing difficulty breathing, swallowing or snoring
How many episodes of tonsilitis in one year indicated tonsillectomy?
7 or more
How many episodes of tonsilitis in two years indicated tonsillectomy?
5 per year
How many episodes of tonsilitis across 3 years indicated tonsillectomy?
3 per year
When might tonsillectomy be indicated for reasons other than a specified number of episodes of recurrent tonsilitis?
Recurrent tonsillar abscesses (2 episodes)
Enlarged tonsils causing difficulty breathing, swallowing or snoring
Potential complications of tonsillectomy
Pain, particularly a sore throat where the tonsillar tissue has been removed. This can last 2 weeks.
Damage to teeth
Infection
Post-tonsillectomy bleeding
Risks of a general anaesthetic
Observation following tonsillectomy?
The procedure is usually performed as a day case, and patients go home 6 – 8 hours after the operation, after a period of observation.
What is the main significant complication following tonsillectomy, and up to when might it occur? Why is it serious?
Post tonsillectomy bleeding is the main significant complication after a tonsillectomy.
Significant bleeding can occur in up to 5% of patients who have had a tonsillectomy and it requires urgent management.
This can happen up to 2 weeks after the operation.
Bleeding can be severe and in rare cases life threatening, usually due to aspiration of blood.
Management of post tonsillectomy bleeding?
Call the ENT registrar and get them involved early
Get IV access and send bloods including a FBC, clotting screen, group and save and crossmatch
Keep the child calm and give adequate analgesia
Sit them up and encourage them to spit the blood rather than swallowing
Make the child nil by mouth incase an anaesthetic and operation is required
IV fluids for maintenance and resuscitation as required
If there is severe bleeding or airway compromise, call an anaesthetist as intubation may be required.
Prior to going back to theatre there are two options for stopping less severe bleeds:
1. Hydrogen peroxide gargle
2. Adrenalin soaked swab applied topically
Otitis media is infection of which part of the ear?
Middle ear: space sitting between tympanic membrane (ear drum) and inner ear (chochlea, vestibular apparatus and nerves)
How does infection occur in otitis media?
The bacteria enter from the back of the throat through the eustachian tube.
A bacterial infection of the middle ear is often preceded by a viral upper respiratory tract infection.
What is the most common bacterial causes of otitis media, as well as other ENT infections such as rhino-sinusitis and tonsillitis?
streptcoccus pneumoniae
Bacterial causes of otitis media?
Streptococcus pneumoniae (most common)
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
Presentation of otitis media
Ear pain
Conductive hearing loss (affected ear)
URTI symptoms: fever, cough, coryzal symptoms, sore throat, feeling generally unwell
Balance issues and vertigo when infection affecting the vestibular system
Discharge from ear (if TM perforated)
Other non specific symptoms: vomiting, irritability, lethargy, poor feeding
In a normal child the tympanic membrane should appear how?
“pearly-grey”, translucent and slightly shiny
You should be able to visualise the malleus through the membrane and a cone of light reflecting the light of the otoscope.
Tympanic membrane in otitis media
Buldging, red, inflamed looking membrane
If perforation: discharge in ear canal and hole in TM
When should consideration for paediatric assessment or admission be considered in children of otitis media?
Consider referral to paediatrics for assessment or admission if symptoms are severe or there is diagnostic doubt.
Always refer for specialist assessment and to consider admission in infants younger than 3 months with a temperature above 38ºC or 3 – 6 months with a temperature higher than 39ºC.
For how long do most cases of otitis media last?
They state that most cases of otitis media will resolve within 3 days without antibiotics, but it can last for up to a week.
General management principals
Most cases of otitis media will resolve without antibiotics, and NICE guidelines from 2018 highlight the importance of not providing antibiotics for otitis media.
Complications (mainly mastoiditis) are rare. Give simple analgesia to help with pain and fever.
There are three options regarding prescribing antibiotics to patients with otitis media:
Immediate antibiotics
Delayed prescription
No antibiotics
Otitis media - considering immediate antibiotics
Consider prescribing antibiotics at the initial presentation in patients who have significant co-morbidities, are systemically unwell or are immunocompromised.
Children less than 2 years with bilateral otitis media and children with otorrhoea (discharge) are more likely to benefit from antibiotics.
Consider delayed prescription of antibiotics -
Consider a delayed prescription that can be collected and used after 3 days if symptoms have not improved or have worsened at any time.
This can be useful with patients that are very keen on antibiotics or where you suspect they might get worse.
What is seen here
bulging, red, inflamed looking membrane suggestive of otitis media
What is seen here
A dull tympanic membrane with air bubbles or a visible fluid level, suggestive of otitis media with effusion
Why does glue ear/OME occur?
The middle ear becomes full of fluid, causing a loss of hearing in that ear.
The Eustachian tube connects the middle ear to the back of the throat.
It helps drain secretions from the middle ear.
When it becomes blocked, this causes middle ear secretions (fluid) to build up in the middle ear space.
What is seen in otoscopy in OME?
Otoscopy can show a dull tympanic membrane with air bubbles or a visible fluid level, although it can look normal.
Audiogram - sensorineural hearing loss
In patients with sensorineural hearing loss, both air and bone conduction readings will be more than 20 dB, plotted below the 20 dB line on the chart. This may affect only one side, one side more than the other or both sides equally.
Audiogram - conductive hearing loss
In patients with conductive hearing loss, bone conduction readings will be normal (between 0 and 20 dB), however air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart. In conductive hearing loss, sound can travel through bones but is not conducted through air due to pathology along the route into the ear.
Audiogram - mixed hearing loss
In patients with mixed hearing loss, both air and bone conduction readings will be more than 20 dB, however there will be a difference of more than 15 dB between the two (bone conduction > air conduction).
What is cleft lip?
Cleft lip is a congenital condition where there is a split or open section of the upper lip. This opening can occur at any point along the top lip, and can extend as high as the nose.
What is cleft palate?
Cleft palate is where a defect exists in the hard or soft palate at the roof of the mouth. This leaves an opening between the mouth and the nasal cavity. Cleft lip and cleft palate can occur together or on their own.
Cleft lip/palate complications
Cleft lip or cleft palate is not life threatening, although it can lead to significant problems with feeding, swallowing and speech.
It can also have significant psycho-social implications, including affecting bonding between mother and child.
Surgery generally resolves these problems.
Children with cleft palates can be more prone to hearing problems, ear infections and glue ear.
Management of cleft lip/pallete
Patients should be referred to the local cleft lip services. This involves the specialist multi-disciplinary team:
Specialist nurses to support and coordinate care
Plastic, maxillofacial and ENT surgeons
Dentists
Speech and language therapists
Psychologists
General practitioners
The first priority is to ensure the baby can eat and drink. This may involve specially shaped bottles and teats. The specialist nurse will follow the child up through surgery and beyond to ensure good development.
The definitive treatment is to surgically correct the cleft lip or palate. This leaves a subtle scar, but is generally very successful, giving full functionality to the child. Cleft lip surgery is usually performed at 3 months, whilst cleft palate surgery done at 6 – 12 months.
When is cleft lip surgery typically performed?
3 months
What is a cystic hygroma?
A cystic hygroma is a malformation of the lymphatic system that results in a cyst filled with lymphatic fluid. It is most commonly a congenital abnormality and is typically located in the posterior triangle of the neck on the left side.
What is this congenital abnormality?
A cystic hygroma
Malformation of the lymphatic system that results in a cyst filled with lymphatic fluid
What abnormality is seen here?
Thyroglossal cyst
What is occuring here as a result of underlying congenital abnormality?
Brachial cyst, forming fue to fluid filling in a space left when the second brachial cleft fails to properly form during fetal development
