ENT

Question 1

Causes of epistaxis

Answer 1

Trauma 
Post-operative 
Tumour 
Coagulation disorder (hereditary haemorrhagic telangiectasia)
Vascular malformations 
Mitral stenosis (raised venous pressure)
Drug use e.g. cocaine

Question 2

Where do the majority of nasal bleeds originate from?

Answer 2

Kisselbach plexus of Little’s area

Question 3

Management of epistaxis

Answer 3

Conservative: press and lean forward, encourage to spit out blood

Referral if 15 mins doesn’t stop

FBC, clotting screen (if on anticoagulant, liver disease or coagulopathy) and Group and Save

Cauterisation: topical local anaesthetic, silver nitrate stick –> topical abx (Naseptin or Mupirocin)

Packing: topical local anaesthetic –> Rapid Rhino/nasal tampons –> 24 hr admission under ENT surgeons for monitoring and NBM in case of surgery –> prophylactic abx

Question 4

Who should you not give Naseptin to?

Answer 4

Allergic to peanuts, soya or neomycin

Question 5

How to manage posterior epistaxis bleeds?

Answer 5

Double balloon catheters applied to posterior nasal cavity (or foley catheter)

Question 6

What should you avoid following epistaxis treatment?

Answer 6

Hot drinks
Picking nose or blowing nose
Lying flat
Strenuous exercise

Question 7

When should you refer a patient with epistaxis following treatment?

Answer 7

Patients under 2 (increased risk of leukemia or haemophilia)

Co-morbidities e.g. HTN or coronary artery disease

High cancer-risk groups: occupational exposure to chemicals, older patients, 12-20 males (angiofibroma), Chinese, signs of cancer, family history

Question 8

How to interpret FeverPAIN score?

Answer 8

1: no abx
2-3: consider delayed abx
4-5: abx indicated

Question 9

What are the elements of FeverPAIN and Centor?

Answer 9

Fever in past 24 hours
Purulent discharge 
Attend rapidly (within 3 days of sx)
Inflamed tonsils (severe)
No cough or coryza 

CENTOR
Tonsillar exudate 
Tender anterior cervical lymphadenopathy 
History of fever >38
Absence of cough

Question 10

Centor score interpretation

Answer 10

0-2: don’t routinely offer abx

3-4: consider empirical abx

Question 11

Most common bacterial cause of tonsillitis

Answer 11

Group A beta haemolytic strep

Question 12

Antibiotics used to treat tonsillitis

Answer 12

Phenoxymethylpenicillin

erythromycin or clarithromycin if pen allergy

Question 13

Features of tonsillitis

Answer 13

Trismus 
White exudate on tonsils 
Fever 
Sore throat 
Dysphagia 
Lymphadenopathy 
Dysphagia 
Malaise

Question 14

Management of severe tonsillitis

Answer 14

Severe dysphagia and fever
IV fluids, abx and dose of IV steroids
Admission for monitoring

Question 15

When should you suspect epiglottitis in a patient?

Answer 15

Drooling, trismus, stridor or severe sore throat

Question 16

What patients are at risk of severe tonsillitis?

Answer 16

Those at risk of agranulocytosis (e.g. taking carbimazole) - hold abx and send FBC

Immunosuppressed

Question 17

What are the complications of tonsillitis?

Answer 17

Suppurative: quinsy, acute otitis media, acute sinusitis

Non-suppurative: rheumatic fever, glomerulonephritis

Question 18

What are the indications for tonsillectomy?

Answer 18

Suspected malignancy

More than one episode of quinsy or airway obstruction

Recurrent sore throat with disabling episodes (At least 7 in the last year, 5 in the last two years or three in preceding three years)

Obstructive sleep apnoea

Children: failure to thrive, sleep apnoea, impacting quality of life