ENT Flashcards
What is the most common cause of tonsillitis?
Viral infection - do not require or respond to antibiotics.
What are the most common bacterial causes of tonsillitis?
- Streptococcus pyogenes
- Streptococcus pneumoniae
Peak ages for tonsillitis.
5 to 10
15 and 20
Presentation of tonsillitis.
- fever
- sore throat
- painful swallowing
What is the Centor criteria?
Estimates the probability that tonsillitis is due to bacterial infection, and will therefore benefit from abx.
CENTOR ≥3:
- fever > 38°C
- tonsillar exudates
- absence of cough
- tender lymphadenopathy
Tonsillitis differentials.
- meningitis
- epiglottitis
- peritonsillar abscess
Management of viral tonsillitis.
- simple analgesia to control pain and fever
- return if not settled within 3 days or fever >38.3°C
- consider delayed antibiotic prescription
Management of bacterial tonsillitis.
Phenoxymethylpenicillin 10/7
Tastes bad so young children are reluctant to take it.
Clarithromycin recommended in true penicillin allergy.
Complications of tonsillitis.
- chronic tonsillitis
- peritonsillar abscess
- otitis media
- Scarlet fever
- Rheumatic fever
- post-streptococcal glomerulonephritis
- post-streptococcal reactive arthritis
What is a peritonsillar abscess?
Bacterial infection with trapped pus, forming an abscess in the region of the tonsills.
Presentation of peritonsillar abscess.
Symptoms of tonsillitis plus:
- trismus (unable to open mouth)
- change in voice due to pharyngeal swelling
- drooling
Cause of peritonsillar abscess.
Bacterial infection:
- Streptococcus pneumoniae
- Staphylococcus aureus
- Haemophilus influenzae
Management of quinsy.
Refer to ENT for incision and drainage under general anaesthetic.
IV antibiotics should be given.
When is tonsillectomy recommended?
≥ 7 episodes in 1 year.
≥ 5 episodes per year for 2 years.
≥3 episodes per year for 3 years.
Complications of tonsillectomy.
- sore throat
- damage to teeth
- infection
- post-tonsillectomy bleeding
- risk of general anaesthetic
What is post tonsillectomy bleeding?
Significant bleeding that occurs within 2 weeks of the operation, which may result in life-threatening aspiration of blood.
Management of post tonsillectomy bleeding.
- call ENT registrar
- IV access and send bloods (FBC, clotting screen, G&S, Xmatch)
- sit child up and encourage to spit
- NBM
- IV fluids
Aetiology of otitis media.
Most common bacterial cause is Streptococcus pneumoniae.
Other causes include:
- haemophilus influenzae
- Moraxella catarrhalis
- Staphylococcus aureus
Presentation of otitis media.
- ear pain
- reduced hearing
- fever
- cough
- coryzal symptoms
- sore throat
- vertigo
- discharge
Examination findings of otitis media.
Tympanic membrane:
- bulging
- red
- inflamed
Where there is perforation, you may see discharge.
Management of otitis media.
Most cases will resolve without antibiotics within 3 days - simple analgesia for pain and fever.
Antibiotic prescription for otitis media.
Immediate antibiotics - significant comorbidities, systemically unwell or immunocompromised.
Delayed prescription - collect after 3 days, useful for patients keen on antibiotics.
Complications of otitis media.
- otitis media with effusion
- hearing loss
- perforation
- recurrent infection
- mastoiditis
- abscess
Pathophysiology of otitis media with effusion (OME).
Blockage of the eustachian tube causes middle ear secretions to accumulate in the middle ear space.
Features of OME.
- reduction in hearing
- ear pain
- discharge
OME examination findings.
Otoscopy:
- dull tympanic membrane
- retracted tympanic membrane
- air bubbles
- visible fluid level
Management of OME.
Audiometry referral to diagnose the extent of hearing loss.
Treat conservatively and self-resolves within 3 months.
Grommet’s if persistent.
Which comorbidities are associated with OME?
- Down’s syndrome
- cleft palate
What are the broad causes of hearing loss?
- congenital
- perinatal
- postnatal
Congenital causes of hearing loss.
- maternal rubella infection
- maternal CMV infection
- genetic deafness
- Down’s syndrome
Perinatal causes of hearing loss.
- prematurity
- hypoxia during birth
Postnatal causes of hearing loss.
- jaundice
- meningitis
- encephalitis
- otitis media / OME
- chemotherapy
What screening is used to identify congenital hearing problems early?
Newborn hearing screening programme tests hearing in all neonates.
Involves specialist equipment that delivers sound to each eardrum individually, and checks for a response.
Presentation of hearing loss.
- ignoring calls or sounds
- frustration or bad behaviour
- poor speech and language development
- poor school performance
Management of hearing loss.
Diagnosis confirmed by audiometry. MDT involvement:
- SALT
- educational psychologist
- ENT specialist
- hearing aids
- sign language
Where do most nosebleeds originate?
Kiesselbach’s plexus - AKA Little’s area.
Little’s area is is most commonly affected by the Little fingers.
Presentation of nosebleeds.
Unilaterally bleeding.
May present with vomiting blood if children swallow blood during a nosebleed.
Nosebleed triggers.
- nose picking
- colds
- vigorous nose blowing
- trauma
- changes in weather
First aid management of nosebleeds.
- sit up and tilt the head forwards
- squeeze the soft part of the nostrils together for 10-15 minutes
- spit any blood rather than swallowing
Safety netting advice for nosebleeds.
Go to hospital if:
- bleeding doesn’t stop after 10 minutes
- severe bleeding
- bilateral bleeding
- unstable
Hospital treatment of nosebleeds.
- Nasal packing using nasal tampons.
- Nasal cautery using a silver nitrate stick.
After treating a nosebleed, what is the role of naseptin?
Reduces crusting, inflammation and infection.
Contraindications of naseptin.
- peanut allergy
- soya allergy
What is cleft lip?
Congenital condition causes a split or open section in the upper lip.
Cleft palate if the defect exists in the hard or soft palate at the roof of the mouth.
Causes of cleft lip.
Occur randomly most of the time.
Associations with family history (loosely).
Complications of cleft palate.
Issues with:
- feeding
- swallowing
- speech
- psycho-social implications
Management of cleft lip.
Refer to cleft lip services.
First priority is to ensure baby can eat and drink, involving specially shaped bottles and teats.
Definitive treatment is to surgically correct the cleft lip or palate.
What is tongue tie?
Baby is born with a short and tight lingual frenulum, preventing them extending their tongue out of the mouth.
Presents as poor feeding.
Management of tongue tie.
Frenotomy - cutting the tongue tie.
Can be done on the ward or in the clinic without any anaesthetic.
What is a cystic hygroma?
Malformation of the lymphatic system resulting in a cyst filled with lymphatic fluid.
Features of cystic hygroma.
Most commonly present on the neck or armpit:
- large
- soft
- non-tender
- transilluminate
Complications of cystic hygroma.
Interfere with feeding, swallowing or breathing.
Infection - hot and tender.
Haemorrhage into the cyst.
Management of cystic hygroma.
Aspiration, surgical removal and sclerotherapy are treatment options.
If mild, may be able to watch and wait for regression.
Pathophysiology of thyroglossal cyst.
In fetal development, the thyroid gland migrates from the base of the tongue down to the neck in its final position infront of the trachea.
It leaves a track behind called the thryoglossal duct, which usually obliterates. If obliteration doesn’t occur, it can give rise to a fluid filled cyst.
Differentials for thyroglossal cyst.
- ectopic thyroid tissue
Diagnostic workup of thyroglossal cyst.
- ultrasound
- CT scan
Management of thyroglossal cyst.
Surgical removal to provide confirmation of the diagnosis on histology and prevent infections.
The cyst can reoccur after surgery unless the full thyroglossal duct is removed.
Pathophysiology of branchial cyst.
Congenital abnormality when the second branchial cleft fails to form properly, leaving a space surrounded by epithelial tissue in the lateral neck.
The space can fill with fluid, resulting in a branchial cyst.
Features of branchial cyst.
- round
- soft
- cystic
- anterior triangle of neck
What is a branchial cleft sinus?
When the branchial cyst is connected via a tract to the outer skin surface - there is a small hole visible in the skin beside the cyst.
What is a branchial fistula?
A connecting tract between the oropharynx to the outer skin surface via a branchial cyst.
Management of branchial cyst.
Surgical excision appropriate if recurrent infection or diagnostic uncertainty.
Histological confirmation.
