ENT Flashcards
What is stridor?
High pitched sound/ whistling on inspiration
Commonly caused by a lower respiratory tract infection - below the larynx
What are differentials for stridor (children)?
Croup ( commonly caused by a virus - typically parainfluenza virus)
Epiglottitis (bacterial cause - Haemophilus influenza B)
Anaphylaxis
Foreign body
Trauma
Congenital
What are differentials for stridor (adults)?
Laryngitis
FB
Trauma
Epiglottitis
Laryngeal tumour
Anaphylaxis
Iatrogenic - neck surgery/ prolonged intubation
What is epiglottitis? Aetiology? Risk factors?
Inflammation of the epiglottitis (closes to prevent food bolus entering the trachea)
Medical emergency
Invasion of bacteria to the epiglottitis or supraglottic tissue
Bacterial cause - commonly haemophilus influenza b/ streptococcus pneumonia/ streptococcus aureus
Risk factors - young children 6-12/ unvaccinated/ immunocompromised
Epiglottitis - signs + symptoms
Swollen epiglottitis
Erythema
Severe sore throat
Dysphagia
Odynophagia
Drooling
Distress
3 D’s - drooling/ distress/ dysphagia
Children ( few hours)/ Adults (few days)
Epiglottitis - investigations + management
Clinically diagnosed -
if pt stabilised further investigation can be considered
Soft tissue x-ray - thumbprint sign
Emergency management
Call secondary care
O2 supplementation
IV fluids
IV anti-biotics - ceftriaxone
If awaiting ambulance consider nebulised adrenaline
Nasopharyngeal + oral cancer risk factors
South Asian background
Aged 40-70
EBV (nasal)
Males
Smoking
Excessive alcohol intake
Chewing tobacco
HPV
Nasopharyngeal + oral cancer signs + symptoms
Palpable mass/ lump
Painless ulcerations
Bleeding of mouth/gums
Dysphagia
Swelling of lymph nodes
Blood tinged sputum
Unilateral hearing loss
Localised pain
Changes to appetite
Head + neck cancer diagnosis?
US of neck/ biopsy/ MRI or CT/ laryngoscopy
Tonsillitis - diagnosis/ aetiology/ risk factors
Inflammation of tonsils
Causes -
Viral - adenovirus/ EBV/ parainfluenza etc
Bacterial - commonly streptococcus A
Risk factors-
Younger age/ family history / immunosuppressed
Tonsillitis - Investigations/ management
Clinical diagnosis
Not routinely performed - microbiological testing/ throat culture/ rapid antigen test
Management -
Viral - conservative/ hydration/ salt water/ analgesia
Bacterial - anti-biotics
1st line - phenoxymethylpenicillin
2nd line -
Clarithromycin
3rd line-
Erythromycin if pregnant
What are the Group A streptococcus tonsillitis diagnosis criteria?
Centre criteria
FeverPAIN criteria
Score 3-4 - anti-biotics are recommended
Quinsy - definition + aetiology/ risk factors
Commonly occurs as a complication of acute tonsillitis/ bacterial cause
Formation of an abscess between the wall of pharynx and tonsil
RF- Acute tonsillitis/ 5-25yrs
Quinsy - Investigations + management
Clinical diagnosis
Routine blood test - FBC, U&E, CRP, LFTs - access inflammatory markers + dehydration
Swab culture
Management-
Immediate referral to ENT
Drainage of abscess - aspiration
IV antibiotics - amoxicillin/ clarithromycin
Possible tonsillectomy
Quinsy - signs + symptoms
Recent/ recurrent tonsilitis
Dysphagia
Earache
Headache/ malaise
Drooling
Fever
Trismus
Glandular fever - definition/ aetiology/ presentation
Transmitted through saliva/ commonly caused by EBV virus (epstein-barr virus) - human herpes virus
Spread through kissing , sharing food , drink + utensils
Most common adolescents + young people
90% by age 40
Sore throat/ malaise/ fatigue. myalgias
Fever/ tonsillar exudate/ cervical lymph nodes/ rash/ splenomegaly/ hepatomegaly
Glandular fever - symptoms/ diagnosis
FBC - lymphocytes
Monospot test - tests body’s immune response to EBV infection
Fever/ lymph nodes/ severe sore throat/ tonsillar exudate/ enlargement/ pharyngeal inflammation/ non-specific rash/ splenomegaly (2 weeks after)/ hepatomegaly
Glandular fever - Management
Mostly self-limiting lasts 2 - 4 weeks
May last longer few months
Analgesia
Fatigue is common - patient education
Avoid collision sports + heavy lifting - due to increased risk of splenic rupture
Advise to limit spread of disease
Arrange hospital admission if serious complications suspected
Risk factors of pharyngitis?
Group A streptococcus contact
Oral sex
Immunocomprised
ICS
Management of pharyngitis?
Conservative - fluid intake/ analgesia/ salt water
Viral - conservative management
Bacterial - Antibiotics - 1st line - phenoxymethypenicillin
2nd line - Clarithromycin
If pregnant - erythromycin
Candida - Nystatin
Chlamydia - doxycycline
Gonorrhoea - Ciprofloxacin
Management of laryngitis?
Acute - self-limiting
Avoid smoking/ alcohol/ rest voice/ hydration
Fever/ sputum for more than 48 hours - anti-biotics
Chronic laryngitis- Referred for laryngoscopy
Urgent referral - Weight loss/ neck mass/ dysphagia/ odynophagia/ recent intubation or radiotherapy
Management of aphthous ulcers?
Saline mouthwash/ antiseptic mouthwash/ local anaesthetics (bonjela)
Recurrent ulceration - routine referral
Ulceration more than 3 weeks - 2WW maxillofacial surgeons
2WW criteria for oral cancer
Unexplained ulceration in oral cavity for more than 3 weeks / Unexplained lump/ Red or white patch in oral cavity / Persistent unexplained hoarseness
Oral candidiasis - aetiology/ risk factors/ symptoms
Overgrowth of normal GI flora yeast like fungus - candida species (can be rubbed off)
RF’s - oral or inhaled steroids/ broad spectrum anti-biotics/ diabetes/ denture wearing/ anaemia/ vit B12 deficiency/ smoking/ prolonged antibiotic use/ extremes of age
Symptoms - usually asymptomatic
mouth soreness/ problems swallowing
Signs - acute erythematous/ angular cheilitis
Oral candidiasis - investigations/ management
Clinical
If recurrent/ severe screen for underlying diaginosis
Investigations - FBC (look for anaemia/ iron + B12 deficiency/ HbA1c
Oral examination
Management -
Hygiene advice (e.g cleaning dentures)
Smoking cessation
Control diabetes
ICS - advice on rinsing mounth
1st line - miconazole oral gel - continue 2 days after symptoms start
1st line - immunocomprised - fluconazole oral
Hospital admission - widespread candidiasis
Oral leukoplakia (definition/ aetiology/ symptoms?)
Thick, white patches in the oral cavity - white discoloration that cant be rubbed off
Aetiology - repeated injury or irritation/ vitamin deficiencies/ dentures etc
Chronic candidiasis
Usually asymptomatic
Oral leukoplakia (risk factors/ investigations/ management)
Ill fitting dentures/ smoking/ alcohol/ endocrine disturbances
FBC - vit deficiency
Swab if suspecting candida
Refer for biopsy if lesion appear suspicious
Management - refer to ENT for biopsy
HSV definition/ aetiology/ symptoms
Oral herpes simplex virus (HSV)
‘Cold sore’
90% HSV 1
Transmitted via direct contact of skin or mucous membranes with infected secretions
Primary infection - remains dormant - can lead to recurrent infections
Symptoms -
Prodrome - pain/ burning/ tingling
Painful blisters
Fever/ malaise/ sore throat
Cervical lymphadenopathy
Clustered erythematous vesicles
Oral herpes simplex virus (HSV) diagnosis + management?
Clinical
Swab for HSV if diagnosis unclear
Management -
Topical anti-viral OTC
Oral antiviral - primary/ severe/ recurrent or immunocomprised
Minimise infection risk
Sialadenitis - definition/ signs + symptoms + management
Infection of the major salivary glands - transmission of bacteria from oral cavity via the salivary duct
Symptoms -
Enlarged painful salivary gland
Decreased salivary secretion
Red/painful duct
Management-
Heat/cold compression
Hydration
Lemon drops/ citrus drops - promote salivary flow
Analgesia medication
Acute sinusitis - definition/ aetiology/ risk factors
D- symptomatic inflammation of paranasal sinuses for <12 weeks (Frontal/ ethmoid + maxillary sinuses)
A- Viral URI - less than 2% - bacterial infection
Haemophilus influenza/ staphylococcus aureus
RF’s - Allergic rhinitis/ asthma/ smoking/ nasal polyps etc
Acute sinusitis - signs + symptoms/ diagnosis
Previous UTI symptoms
Symptoms lasting more than 10 days
Nasal blockage
Rhinorrhea
Facial pressure/ pain
Maxillofacial sinus swelling
Discoloured nasal discharge
Fever
Nasal mucosa oedema
Diagnosis
Clinical
Acute sinusitis -management
Conservative management
Analgesia/ nasal decongestant/ nasal saline spray
Symptoms more than 10 days -
Consider high dose nasal corticosteroid - 2 weeks
Consider back-up anti-biotic prescription - phenoxymethylpenicillin or co-amoxiclav for 5 days
Chronic sinusitis - definition/ aetiology/ signs + symptoms
Symptomatic paranasal sinus inflammation for more than 12 weeks
A- inflammatory rather than infectious
RF’s - Atopy/ asthma/ aspirin sensitivity - can lead to nasal polyps/ smoking/ immunocomprised
Symptoms - same as acute
Signs - maxillofacial tenderness/ pain/ inflamed nasal mucosa
Chronic sinusitis - diagnosis/ management
Clinical diagnosis
CT scan of sinuses - ordered by ENT
Management
Supportive care
Smoking cessation/ avoid allergic triggers
Nasal saline
Intranasal corticosteroid - 3 months
Seek specialist advice if considering anti-biotics
More than 3 months - refer to ENT
Allergic rhinitis - definition/ aetiology
D- IgE-mediated inflammatory disorder of the nose
Nasal mucosa sensitised to allergens, causing release of histamine
A- Causes
Genetics
Environmental
House dust mites
Grass, tree, weed pollens
Moulds
Animal dander
Allergic rhinitis - diagnosis
Clinical diagnosis
Consider ENT referral - persistent symptoms despite primary care management
Allergy testing, immunotherapy, skin prick testing
Nasal obstruction or structural abnormality
Allergic rhinitis - management
Mild - moderate -
As needed intranasal antihistamine (azelastine) or non -sedating oral antihistamine
Moderate to severe -
Daily intranasal corticosteroid - allergen exposure - up to 2 weeks to be effective
Saline nasal spray + allergen avoidance
Treatment failure -
Compliance
Consider stepping-up treatment
Nasal congestion - add intranasal decongestant x5-7 days
Rhinorrhoea - add intranasal anticholinergic (ipratropium bromide)
Nasal itching, sneezing - add regular oral antihistamine or combination intranasal antihistamine with corticosteroid (Dymista)
Concurrent asthma - add leukotriene receptor antagonist (montelukast)
Severe symptoms affecting QOL
Short-course oral corticosteroid (prednisolone) x5-10 days
Refer for immunotherapy - IgE sensitivity
Nasal polyps - definition/ risk factors
Benign swellings of nasal mucosa of paranasal sinuses
Often associated with chronic sinusitis
Risk factors
Asthma
Eosinophilic granulomatous polyangiitis (EGPA)
Aspirin sensitivity
Genetics
Nasal polyps - symptoms. signs/ diagnosis
Symptoms
Nasal obstruction
Most often bilateral
Nasal discharge
Facial pain/pressure
Reduced sense of smell (anosmia)
Cough
Postnasal drip
Signs
Visualisation of nasal polyp(s)
Nasal discharge
Diagnosis
Clinical diagnosis
Nasal endoscopy
If not visualized via anterior rhinoscopy
CT scan sinuses
If unilateral symptoms, concern for neoplasm
(eg bleeding, foul odour, impaired vision etc)
Nasal polyps - management
1st-line
Intranasal corticosteroid
Daily x3 months, then re-evaluate
Continue indefinitely with review q 6 months
Nasal saline irrigation
+/- doxycycline x3-12 weeks
2nd-line
Surgical polypectomy
Epistaxis - definition/ aetiology
Nosebleed
80-95% originate anterior nasal septum, location of Kiesselbach plexus of vessels
Less common posterior epistaxis
Older patients, bilateral bleeding, more profuse
Trauma
Inflammation
Infection (eg chronic sinusitis), allergic rhinitis, nasal polyps
Topical drugs
Cocaine, decongestants, corticosteroids
Systemic drugs
Anticoagulants, antiplatelets (eg aspirin, clopidogrel)
Tumours
Nasal oxygen therapy
Clotting disorders
Excessive alcohol consumption
Environmental factors
Humidity, altitude, temperatures, cigarette smoke, dust
Epistaxis - diagnosis
Perfused nose bleed
Anterior rhinoscopy to identify bleed location
Ask patient to first gently blow nose to remove clots
Bleeding point appears as small red dot
Suspect posterior bleed if
Unable to visualize, bleeding first began down throat, profuse bleeding, bilateral bleeding
FBC, coagulation studies if underlying cause suspected or significant bleeding
Epistaxis - management
Admit if suspect posterior epistaxis or haemodynamically unstable
First aid measures
Patient sit upright, leaning slightly forward while pinching cartilaginous nose x10-15 minutes
If bleeding stops, prescribe topical antiseptic (Naseptin) applied to nares QD x10 days and recommend avoid following
for 24 hours:
Blowing nose, heavy lifting, strenuous
exercise, lying supine, avoid alcohol/hot drinks
If first aid unsuccessful after 15 minutes
Nasal cautery - silver nitrate stick
Nasal packing
Fractured nose
See within 7 days - ENT
Refer immediately if
Gross displacement
Compound - bone protruding skin
Uncontrolled bleed
CSF rhinorrhoea - nasal or head trauma - sign of skull fracture
Septal haematoma
Septal
Gently palpate
If boggy = haematoma
If hard = displaced cartilage or turbinate
If you suspect it - refer immediately
Treatment for epistaxis?
If direct compression of the nasal alae for 10-15 minutes does not resolve epistaxis.
the next most appropriate management step would be nasal cautery as there is a visible bleeding site amenable to cautery.
Lifestyle advice should be given once the bleeding is controlled
