ENT Flashcards
Give 4 complications of tonsillitis?
Complications of tonsillitis include:
otitis media
quinsy - peritonsillar abscess
rheumatic fever and glomerulonephritis very rarely
Give 4 main indications for tonsillectomy? Give 3 alternate indications
The indications for tonsillectomy are controversial. NICE recommend that surgery should be considered only if the person meets all of the following criteria
-sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
-the person has five or more episodes of sore throat per year
-symptoms have been occurring for at least a year
-the episodes of sore throat are disabling and prevent normal functioning
Other established indications for a tonsillectomy include
-recurrent febrile convulsions secondary to episodes of tonsillitis
-obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
-peritonsillar abscess (quinsy) if unresponsive to standard treatment
Give the primary and secondary complications of tonsillectomy
Complications of tonsillectomy
-primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain
-secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain
What does sore throat encompass? Describe the management
Sore throat encompasses pharyngitis, tonsillitis, and laryngitis.
Clinical Knowledge Summaries recommend:
throat swabs and rapid antigen tests should not be carried out routinely in patients with a sore throat
Management
paracetamol or ibuprofen for pain relief antibiotics are not routinely indicated there is some evidence that a single dose of oral corticosteroid may reduce the severity and duration of pain, although this has not yet been incorporated into UK guidelines
Give 5 indications for antibiotics in sore throat
NICE indications for antibiotics
-features of marked systemic upset secondary to the acute sore throat
-unilateral peritonsillitis
-a history of rheumatic fever
-an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
-patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
What is in the centor criteria? give the likelihood of isolating strep according to the centor score
The Centor criteria are: score 1 point for each (maximum score of 4)
-presence of tonsillar exudate
-tender anterior cervical lymphadenopathy or lymphadenitis
-history of fever
-absence of cough
Centor score Likelihood of isolating Streptococci
0 or 1 or 2 3 to 17%
3 or 4 32 to 56%
What is the FeverPAIN criteria? give the likelihood of isolating strep according to the fever pain score.
The FeverPAIN criteria are: score 1 point for each (maximum score of 5)
-Fever over 38°C.
-Purulence (pharyngeal/tonsillar exudate).
-Attend rapidly (3 days or less)
-Severely Inflamed tonsils
-No cough or coryza
FeverPAIN score Likelihood of isolating Streptococci
0 or 1 13 to 18%
2 or 3 34% to 40%
4 or 5 62% to 65%
What is acute sinusitis? What are the most common infectious agents seen? give 4 predisposing factors
Sinusitis describes an inflammation of the mucous membranes of the paranasal sinuses. The sinuses are usually sterile - the most common infectious agents seen in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses.
Predisposing factors include:
-nasal obstruction e.g. septal deviation or nasal polyps
-recent local infection e.g. rhinitis or dental extraction
-swimming/diving
-smoking
Give 3 features of sinusitis
Features
-facial pain
typically frontal pressure pain which is worse on bending forward
-nasal discharge: usually thick and purulent
-nasal obstruction
Give 5 management points on acute sinusitis? what may occur in sinusitis?
Management of acute sinusitis
-analgesia
-intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited
-NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days
-oral antibiotics are not normally required but may be given for severe presentations.
-The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’
-‘double-sickening’ may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection
What is chronic rhinosinusitis? Give 5 predisposing factors
Chronic rhinosinusitis affects up to 1 in 10 people. It is generally defined as an inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer.
Predisposing factors include:
-atopy: hay fever, asthma
-nasal obstruction e.g. Septal deviation or nasal polyps
-recent local infection e.g. Rhinitis or dental extraction
-swimming/diving
-smoking
Give 4 features of chronic rhinosinusitis
Features
-facial pain: typically frontal pressure pain which is worse on bending forward
-nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection
-nasal obstruction: e.g. ‘mouth breathing’
-post-nasal drip: may produce chronic cough
Give 3 management options for chronic rhinosinusitis? Give 3 red flag symptoms
Management of recurrent or chronic sinusitis
avoid allergen intranasal corticosteroids nasal irrigation with saline solution
Red flags symptoms
-unilateral symptoms
-persistent symptoms despite compliance with 3 months of treatment
-epistaxis
What is allergic rhinitis? What are 3 classifications
Allergic rhinitis is an inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens. It may be classified as follows, although the clinical usefulness of such classifications remains doubtful:
-seasonal: symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is known as hay fever
-perennial: symptoms occur throughout the year
-occupational: symptoms follow exposure to particular allergens within the work place
Give 5 features of allergic rhinitis?
Features
-sneezing
-bilateral nasal obstruction
-clear nasal discharge
-post-nasal drip
-nasal pruritus
Give 4 management points of allergic rhinitis?
Management of allergic rhinitis
-allergen avoidance
-if the person has mild-to-moderate intermittent, or mild persistent symptoms: oral or intranasal antihistamines
-if the person has moderate-to-severe persistent symptoms, or initial drug treatment is ineffective: intranasal corticosteroids
-a short course of oral corticosteroids are occasionally needed to cover important life events
-there may be a role for short courses of topical nasal decongestants (e.g. oxymetazoline). They should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal
How common are nasal polyps? Give 6 associations
Around in 1% of adults in the UK have nasal polyps. They are around 2-4 times more common in men and are not commonly seen in children or the elderly.
Associations
-asthma (particularly late-onset asthma)
-aspirin sensitivity
-infective sinusitis
-cystic fibrosis
-Kartagener’s syndrome
-Churg-Strauss syndrome
What is samters triad? Give 3 features of nasal polyps
The association of asthma, aspirin sensitivity and nasal polyposis is known as Samter’s triad.
Features
nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
What symptoms of nasal polyps require further investigations? What is the management of nasal polyp?
Unusual features which always require further investigation include unilateral symptoms or bleeding.
Management
all patients with suspected nasal polyps should be referred to ENT for a full examination topical corticosteroids shrink polyp size in around 80% of patients
Nasopharyngeal carcinoma:
-What type of cancer is this?
-Where is this most commonly seen?
-What is this assoc. with?
Basics
Squamous cell carcinoma of the nasopharynx Rare in most parts of the world, apart from individuals from Southern China Associated with Epstein Barr virus infection
Give 5 ways nasopharyngeal carcinoma can present?
-Cervical lymphadenopathy -Otalgia
-Unilateral serous otitis media
-Nasal obstruction, discharge and/ or epistaxis
-Cranial nerve palsies e.g. III-VI
What imaging and treatment is indicated for nasopharyngeal carcinoma
Imaging
Combined CT and MRI.
Treatment
Radiotherapy is first line therapy.
What is nasal septal haematoma? Give 5 features of nasal septal haematoma?
How may this be differentiated for a deviated septum?
Nasal septal haematoma is an important complication of nasal trauma that should always be looked for. It describes the development of a haematoma between the septal cartilage and the overlying perichondrium.
Features
-may be precipitated by relatively minor trauma
-the sensation of nasal obstruction is the most common symptom
-pain and rhinorrhoea are also seen
-on examination, classically a -bilateral, red swelling arising from the nasal septum
-this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm
What is the management of nasal septal haematoma? What can happen if this is untreated?
Management
-surgical drainage
-intravenous antibiotics
If untreated irreversible septal necrosis may develop within 3-4 days. This is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis. This may result in a ‘saddle-nose’ deformity
How is epistaxis classified?
Epistaxis (nose bleeds) is split into anterior and posterior bleeds, whereby the former often has a visible source of bleeding and usually occurs due to an insult to the network of capillaries that form Kiesselbach’s plexus.
Posterior haemorrhages, on the other hand, tend to be more profuse and originate from deeper structures. They occur more frequently in older patients and confer a higher risk of aspiration and airway compromise.
Give some causes of epistaxis 8
Causes
-most cases of epistaxis tend to be benign and self-limiting. Exacerbation factors include:
nose picking
nose blowing
-trauma to the nose
-insertion of foreign bodies
-bleeding disorders
immune thrombocytopenia
Waldenstrom’s macroglobulinaemia
-juvenile angiofibroma
benign tumour that is highly vascularised
seen in adolescent males
-cocaine use
-the nasal septum may look abraded or atrophied, inquire about drug use. This is because inhaled cocaine
-cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.
-hereditary haemorrhagic telangiectasia
-granulomatosis with polyangiitis
Describe the first aid measures for epistaxis?
If the patient is haemodynamically stable, bleeding can be controlled with first aid measures. This involves:
-Asking the patient to sit with their torso forward and their mouth open
-avoid lying down unless they feel faint
-his decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth
-it also reduces the risk of aspirating blood
Pinch the cartilaginous (soft) area of the nose firmly
this should be done for at least 20 minutes
also ask the patient to breathe through their mouth.
Describe the management of epistaxis if first aid measures are successful
If first aid measures are successful
-consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis
cautions to this include patients that have peanut, soy or neomycin allergies
Mupirocin is a viable alternative
admission and follow up care may be considered in patients under if
a comorbidity (e.g. coronary artery disease, or severe hypertension) is present, an underlying cause is suspected
they are aged under 2 years (as underlying causes such as haemophilia or leukaemia are more likely in this age group)
self-care advice involves reducing the risk of re-bleeding
patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks should be avoided
Describe the management of epistaxis if bleeding does not stop after 10-15mins of first aid
If bleeding does not stop after 10-15 minutes of continuous pressure on the nose consider cautery or packing
-cautery should be used initially if the source of the bleed is visible and cautery is tolerated
-it is not so well-tolerated in younger children!
-ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume.
-use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect
-identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.
-dab the area clean with a cotton bud and apply Naseptin or Muciprocin
packing may be used if cautery is not viable or the bleeding point cannot be visualised
-anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes
-pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions
-pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack.
-examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel.
-patients should be admitted to hospital for observation and review, and to ENT if available
Who requires admission for epistaxis?
Patients that are haemodynamically unstable or compromised should be admitted to the emergency department
control bleeding with first aid measures in the interim patients with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital.
Epistaxis that has failed all emergency management
may require sphenopalatine ligation in theatre
IS acute otitis media common? What pathogens commonly cause this?
Acute otitis media is extremely common in young children, with around half of children having three or more episodes by the age of 3 years.
Pathophysiology
-whilst viral upper respiratory tract infections (URTIs) typically precede otitis media, most infections are secondary to bacteria, particularly Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
-viral URTIs are thought to disturb the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear via the Eustachian tube
What are 4 features of otitis media
Features
-otalgia
some children may tug or rub their ear
-fever occurs in around 50% of cases
-hearing loss
-recent viral URTI symptoms are -ear discharge may occur if the tympanic membrane perforates
What are 4 findings on otoscopy in acute otitis media?
Possible otoscopy findings:
-bulging tympanic membrane → loss of light reflex
-opacification or erythema of the tympanic membrane
-perforation with purulent otorrhoea
-decreased mobility if using a pneumatic otoscope
Give 3 criteria that are used to diagnose otitis media
Whilst guidelines vary, the majority use the following criteria to diagnose otitis media:
-acute onset of symptoms
otalgia or ear tugging
-presence of a middle ear effusion
bulging of the tympanic membrane, or
otorrhoea
decreased mobility on pneumatic otoscopy
-inflammation of the tympanic membrane
i.e. erythema
Describe the management of acute otitis media
Acute otitis media is generally a self-limiting condition that does not require an antibiotic prescription. There are however some exceptions listed below. Analgesia should be given to relieve otalgia. Parents should be advised to seek medical help if the symptoms worsen or do not improve after 3 days.
Antibiotics should be prescribed immediately if:
-Symptoms lasting more than 4 days or not improving
-Systemically unwell but not requiring admission
-Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
-Younger than 2 years with bilateral otitis media
-Otitis media with perforation and/or discharge in the canal
If an antibiotic is given, a 5-7 day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.
What are 3 common sequelae of acute otitis media
Common sequelae include:
-perforation of the tympanic membrane → otorrhoea
-unresolved with acute otitis media with perforation may develop into chronic suppurative otitis media (CSOM)
-CSOM is defined as perforation of the tympanic membrane with otorrhoea for > 6 weeks
hearing loss
labyrinthitis
Give complications of acute otitis media
Complications:
mastoiditis meningitis brain abscess facial nerve paralysis
What is glue ear? Give 6 risk factors
Glue ear describes otitis media with an effusion (other terms include serous otitis media). It is common with the majority of children having at least one episode during childhood
Risk factors
-male sex
-siblings with glue ear
-higher incidence in Winter and Spring
-bottle feeding
-day care attendance
-parental smoking
Give 3 clinical features of glue ear
Features
-peaks at 2 years of age
-hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood)
-secondary problems such as speech and language delay, behavioural or balance problems may also be seen
Give 3 treatment options for glue ear?
Treatment options include:
-active observation: the management for a child with a first presentation of otitis media with effusion is active observation for 3 months - no intervention is required
-grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months
-adenoidectomy
What is ear wax? Give 3 treatment options
Ear wax is a normal physiological substance which helps protect the ear canal. Impacted ear wax is extremely common and may cause a variety of symptoms including:
pain conductive hearing loss tinnitus vertigo
The main treatment options in primary care are ear drops or irrigation (‘ear syringing’). Treatment should not be given if a perforation is suspected or the patient has grommets. The following drops may be used:
olive oil sodium bicarbonate 5% almond oil
Give 4 causes of otitis externa?
Otitis externa is a common reason for primary care attendance in the UK.
Causes of otitis externa include:
-infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
-seborrhoeic dermatitis
-contact dermatitis (allergic and irritant)
-recent swimming is a common trigger of otitis externa
give the features of otitis externa? what is seen on otoscopy?
Features
-ear pain, itch, discharge
-otoscopy: red, swollen, or eczematous canal
Describe the initial management of otitis externa? 4
The recommended initial management of otitis externa is:
-topical antibiotic or a combined topical antibiotic with a steroid
-if the tympanic membrane is perforated aminoglycosides are traditionally not used*
-if there is canal debris then consider removal
-if the canal is extensively swollen then an ear wick is sometimes inserted
Give 4 second line options for otitis externa management?
Second-line options include
consider contact dermatitis secondary to neomycin oral antibiotics (flucloxacillin) if the infection is spreading taking a swab inside the ear canal empirical use of an antifungal agent
