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