ENT Flashcards
Define acute mastoiditis
Infection involving bone of mastoid air cells
- complication of otitis media
Epidemiology of acute mastoiditis
75% of cases occur in children under 2
- peak incidence at 6-13 months
Rare now due to introduction of abx
Pathophysiology of acute mastoiditis
Mastoid air cells are collection of air-filled spaces located in mastoid process of the temporal bone
- communicate with middle ear via a small canal known as aditus to mastoid antrum
Breakdown of fine trabeculae of mastoid air cells and collection of pus
-> localised bone necrosis which can spread to form a sub-periosteal abscess
- behind pinna
- superior pinna
- over squamous temporal bone
Risk factors for acute mastoiditis
More common in young children
Immunocompromised patients
Pre-existence of cholesteatoma
Symptoms of acute mastoiditis
Hx of acute or recurrent otitis media Otalgia Blocked ear or deafness Pyrexia - can be swinging Infants may present with irritability, excessive crying and feeding problems
Signs of acute mastoiditis
Unwell child - lethargic Bulging red eardrum Ear discharge - with perforated eardrum Oedema of posterior and superior part of deep ear drum Tenderness behind pinna Pinna pushed forwards by swelling
Neurological signs of advanced mastoiditis
Abducens nerve (CN VI) palsy Facial nerve (CN VII) palsy Facial pain due to involvement of CN Va (opthalmic branch of trigeminal nerve)
Differential diagnosis of acute mastoiditis
Infected pre-auricular sinus
Infected/inflamed post-aural lymph node
Langerhans cell histiocytosis
Rhabdomyosarcoma
Investigations for acute mastoiditis
Should not delay treatment
Ear swab - if discharge
Blood tests - raised inflammatory markers
CT head and mastoid with contrast - coalescence of mastoid air cells and opaque mastoid and middle ear
Management of acute mastoiditis
IV abx as inpatient
- depends on organism
- Strep and Staph aureus = co-amoxiclav or ceftriaxone
Oral abx for further 14 days
Implications for surgical management of acute mastoiditis
Uncomplicated mastoiditis that fails to improve clinically after 48 hrs
Continuing pyrexia
Persistent erythema
Presence of complications
Surgical management of acute mastoiditis
Needle aspiration of pus
Incision and drainage
Cortical mastoidectomy to open mastoid antrum and drain infection
Complications of acute mastoiditis
Extracranial - facial nerve palsy - hearing loss - labyrinthitis - subperiosteal abscess - cranial osteomyelitis Intracranial - meningitis, epidural, temporal lobe or cerebral abscess, subdural empyema - dural sinus thrombosis
Define otitis externa
Inflammation of external ear canal
Classification of otitis externa
- acute = less than 3 weeks
- chronic = more than 3 weeks
- localised = infection of hair follicle in ear which can develop into a boil
- diffuse = widespread inflammation of skin and subdermis
Epidemiology of otitis externa
Common - more than 1% of UK
Incidence increases towards end of summer due to warmer temperatures and more swimming
Pathophysiology of otitis externa
Infection of skin in external auditory canal
Bacterial - pseudomonas aeruginosa or staphylococcus aureus
- blockage of canal
- absence of cerumen due to excess cleaning
- trauma
- alternation of pH within the canal
Fungal infection
Risk factors for otitis externa
Hot humid climates Swimming Older age Diabete Mellitus Narrowing/obstruction of auditory canal Over-cleaning leading to lack of wax in canal Wax build up Eczema Trauma Radiotherapy to the ear
Clinical features of otitis externa
Symptoms - Pain - Itching - Discharge - Hearing loss Signs - Oedema - Erythema - Exudate - Mobile tympanic membrane
Differential diagnosis of otitis externa
Acute otitis media with perforation of TM
Furunculosis - infection of hair follicle in the cartilaginous part of the ear canal
Viral infections
Tumours of external auditory canal
Cholesteatoma
Foreign body
Impacted wax
Skin conditions - acne, psoriasis, contact dermatitis, seborrhoeic dermatitis
Management of otitis externa
Avoid getting ear wet
Remove discharge by gently using cotton wool
Remove any hearing aids or earrings
Use painkillers
Antibiotic or antifungal ear drops
Oral abx if cellulitis or lymphadenopathy
Acetic acid and corticosteroid ear drops in chronic otitis externa
Complications of otitis externa
Abscesses
Stenosis of ear canal due to build up of thick dry skin
Perforated ear drum
Cellulitis
Malignant otitis externa - infection spreads to mastoid and temporal bones
Define epistaxis
Bleeding from the nose
Epidemiology of epistaxis
Fairly common
Bimodal distribution
Most common causative factor in children is nose-picking
Relatively rare in children under 2 - refer to ENT
Pathophysiology of epistaxis
Most commonly Little’s area - confluence of blood vessels
- anterior and posterior ethmoidal
- greater palatine
- sphenopalatine
- superior labial
- lateral nasal
Causes of epistaxis
Trauma - nose picking, sneezing, rubbing, coughing, injury
Mucosal irritation - dry air, URTIs, steroid use
Clotting abnormalities - Von-Willebrand’s disease, hereditary haemorrhagic telangiectasia
Risk factors for epistaxis
Activities involving altitude - skiing Strenuous physical activities with risk of nasal trauma or straining - rugby, gymnastics Coagulopathies Hay fever or regular URTIs Medication use
Clinical features for epistaxis
Hx of spontaneous bleeding
May be able to see source of bleeding
May be evidence of septal haematoma
Management of epistaxis
Initial first aid
- lean forward over bowel and encourage to spit any blood out of mouth
- pinch soft part of noise for at least 15 mins
- try to keep calm
- apply icepack to nape of neck or forehead
- check for cessation of bleeding
Primary care / A+E
- local anaesthetic to septum - co-phenylcaine
- nasal cautery with silver nitrate
- refer to ENT
In recurrent cases FBC and clotting profile
Naseptin ointment BD for 2 weeks post discharge
Define peri-orbital cellulitis
Infection of periorbital soft tissue characterised by erythema and oedema
Epidemiology of peri-orbital cellulitis
Primarily of children and adolescents
- peak incidence in children under 10
Twice as common in males
Bi-modal seasonal variation - late winter/early spring
Pathophysiology of peri-orbital cellulitis
Pre-septal (anterior) and post-septal (posterior) cellulitis
- divided by orbital septum - think fibrous, multi laminated structure that attaches peripherally to periosteum of orbital margin to form arcus marginalis
Commonly occurs as result of contiguous spread from paranasal sinuses - ethmoidal sinusitis most common
Common in children due to thinner and dehiscent bone surface of their lamina papyracea and increased diploic venous supply
Most common organisms of peri-orbital cellulitis
Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus - most common Group A strep
Clinical features of pre-septal infections
Eyelid oedema of upper eyelid Absence of orbital signs Normal vision Absence of proptosis Full ocular motility without pain
Clinical features of orbital cellulitis
Orbital signs in addition to worsening oedema
- proptosis
- ophthalmoplegia
- decreased visual acuity
- loss of red colour vision - first sign of optic neuropathy
- chemosis
- painful diplopia
Classification of peri-orbital cellulitis
1 = pre-septal cellulitis
- cellulitis confined to the eyelid
2 = post-septal orbital cellulitis
- inflammation that extends into orbital tissue, no abscess formation
3 = subperiosteal abscess
- abscess forms deep to the periosteum of orbit
4 = intra-orbital abscess
- collection of pus inside or outside the muscle cone
5 = cavernous sinus thrombosis
- extension of orbital infection into cavernous sinus
- lead to bilateral marked eyelid oedema and involvement of 3rd, 5th and 6th cranial nerves
Differential diagnosis of peri-orbital cellulitis
Vesicles of herpes zoster ophthalmicus Erythematous irritation of contact dermatitis Raised, dry plaques of atopic dermatitis Hordeolum or stye Chalazion Dacrocystitis Blepharitis
Treatment of peri-orbital cellulitis
Mild pre-septal = outpatient empiric broad spec oral abx
Orbital cellulitis = hospital admission for IV abx covering most gram + and - bacteria
Supportive therapy with IV fluid hydration and analgesia
Orbital abscesses = urgent surgical drainage
Complications of orbital cellulitis
Complete vision loss - mechanical pressure, compression of arteries and appearance of necrotic areas on optic nerve Neurological complications - encephalomeningitis - cavernous sinus thrombosis - sepsis - intracranial abscess formation
Define acute epiglottitis
Acute, life-threatening condition
- most commonly caused by infection
Epidemiology of acute epiglottitis
Rare - 1-4/100,000
- reduced since haemophilus influenza B (Hib) vaccine introduced
Pathophysiology of acute epiglottitis
Inflammation of epiglottis - flap of cartilage behind the tongue
Commonly caused by haemophilus influenzae and streptococcus pneumoniae
Children are at higher risk of acute airway obstruction due to floppier, broader and longer epiglottis
Causative organisms of epiglottitis
Bacterial
- haemophilus influenza type B
- strep pneumonia
- staph aureus
- Moraxella catarrhalis
Viral
- HSV
- parainfluenzae
- HIV
Candida and aspergillus species in immunocompromised patients
Non-infectious
- thermal injury - steam, crack cocaine smoking
- direct trauma - blind sweep to remove foreign body
- caustic insults - ingesting dishwasher pellets
Risk factors for epiglottitis
Children not receiving the HiB vaccine
Male gender
Immunosuppression
Clinical features of epiglottitis
Dyspnoea Dysphagia Drooling Dysphonia - muffled voice Typically last less than 12 hours No cough High-grade fever, sore throat, dehydration and partial airway obstruction Stridor is a late sign - tripod position - leans forward on outstretched arms with next extended and tongue out
Differential diagnosis of epiglottitis
Laryngotracheobronchitis (Croup)
- distinctive seal-like barking cough
- drooling, stridor and tripod position
- steeple signs of subglottis on neck x-ray
Inhaled foreign body
- sudden onset
- no fever initially
- may see radio-opaque foreign bodies on neck x-ray
Retropharyngeal abscess
- CT shows abscess
- normal epiglottis and swollen retropharyngeal space on laryngoscopy
Tonsillitis
- bilateral erythematous tonsils with exudate
- longer clinical hx
Peritonsillar abscess
- unilaterally displaced tonsil with peritonsillar erythema and swelling, deviated uvula
- collection of fluid with enhanced rim on CT
Diphtheria
- thick membrane over posterior pharynx
- unvaccinated child
- corynebacterium diphtheria found on microbiology assay
Investigations for epiglottitis
Secure airway Keep calm Throat swabs Blood tests - FBC, cultures and CRP Lateral neck x-ray - thumb-print signs (swollen epiglottis) - thickened aryepiglottic folds - increased opacity of larynx and vocal cords CT/MRI if no response and airway securted
Management of epiglottitis
Secure airway
- early escalation to on-call anaesthesia and ENT registrar
- avoid exacerbation distress
Oxygen
Nebulised adrenaline
IV abx
- 3rd generation cephalosporins - ceftriaxone
- converted to oral once stable and extubates
IV steroids
IV fluids
- resuscitation and maintenance
Complications of epiglottitis
Mediastinitis
- infection spreads to retropharyngeal space
Deep neck space infection
- retropharyngeal or parapharyngeal cellulitis/abscess
Pneumonia
- following intubation
Meningitis
- haemophilus influenzae type B infection
Sepsis/bacteraemia
Define quinsy
Peritonsillar abscess
Collection of pus in peritonsillar space
- complication of tonsillitis
Epidemiology of peritonsillar abscess
More common in young adults - peak incidence between 20-40 yrs
Pathophysiology of peritonsillar abscess
Result of tonsillitis - causing irritation and cellulitis in peritonsillar space, suppuration and collection of pus
Most common organism is group A streptococcus
- 15-24 years old most commonly Fusobacterium necrophorum
- 30-39 years old most commonly group A Streptococcus
Risk factors of peritonsillar abscess
Recurrent episodes of tonsillitis or partially treated episodes following multiple abx
Significantly increased risk in smokers
Clinical features of peritonsillar abscess
Severe sore throat
Drooling/unable to swallow saliva
Trismus - muscle spasm preventing jaw opening to full extent
Hot potato voice
Halitosis
Fever Otalgia
Fever
Unilateral tonsillar inflammation
Deviation of uvular away from affected side
Restricted opening of jaw
Fullness/fluctuant swelling superior to tonsil
Differential diagnosis of peritonsillar abscess
Tonsillitis
Peritonsillar cellulitis
Parapharyngeal/retropharyngeal abscess
Epiglottitis
Investigations for peritonsillar abscess
FBC - elevated WCC, neutrophil predominance
U+E - dehydrated due to poor oral intake - elevated creatinine and urea
CRP
Glandular fever screen
Management of peritonsillar abscess
Aspiration or incision and drainage/ needle aspiration
Abx - co-amoxiclav or benzylpenicillin or metronidazole
IV rehydration
Steroid therapy
Define tonsillitis
Inflammation of palatine tonsils
- concentration of lymphoid tissue within oropharynx
Common causative organisms of tonsillitis
Adenovirus
Epstein Barr virus
Group A strep (strep pyogenes)
Risk factors for tonsillitis
Smoking - second hand or personal
Clinical features for tonsillits
Last between 5-7 days Odynophagia Fever Reduced oral intake Halitosis New onset snoring SOB Red inflamed tonsils White exudate spots on tonsils Cervical lymphadenopathy
Features of FeverPAIN score
1 point each
- fever during past 24hours
- purulence
- attended rapidly - within 3 days of onset of other symptoms
- severely inflamed tonsils
- no cough of coryza
Outcome of Fever PAIN score
0-1 suggests low chance of strep cause
2-3 shows medium chance so consider delayed prescription of abx
4-5 is high chance of strep cause so consider abx
Differential diagnosis of tonsillitis
Quinsy Pharyngitis Glandular fever Tonsillar malignancy Epiglottitis
Management of tonsillitis
Consider inpatient admission - respiratory compromise - risk of dehydration - no improvement despite treatment in the community Abx - benzylpenicillin for 7-10 days Analgesia - paracetamol and ibuprofen Steroids Operative removal - 7 or more episodes in one year
Complications of tonsillitis
Peritonsillar abscess
Deep neck space abscess
Recurrent tonsillitis
Define PSGM
Post-streptococcal glomerulonephritis
Classic triad of hypertension, haematuria and oedema
Define rheumatic fever
Autoimmune response to GAS
-> rheumatic heart disease, prolonged fever, anaemia, arthritis
Define glandular fever
Colloquial term for infectious mononucleosis (IM)
Caused by Epstein-Barr virus
Epidemiology of glandular fever
Commonly acute presentation in teenagers and young adults (18-22) and age 1-6
Risk factors for glandular fever
Common transmission by exchange of saliva
Incubation period of 6 weeks
Spread by blood transfusion and stem cell and solid organ transplant
Clinical features of glandular fever
Sore throat Snoring and sleep apnoea Swollen neck Feverish Headaches N+V Generally tired despite adequate sleep Generalised aches and pains in muscles joints Enlarged inflamed tonsils Significant cervical lymphadenopathy Abdominal tenderness and splenomegaly Hepatomegaly Palatal petechiae
Differential diagnosis of glandular fever
Tonsillitis - bacterial is generally shorter lived
Quinsy - tends to be unilateral
Investigations for glandular fever
FBC - raised WCC LFTs - raised Monospot testing - identifying Epstein-Barr virus - detection of non-specific heterophile IgM autoantibodies - may take a week to appear ELISA based immunoassays - more specific
Management of glandular fever
Antivirals
- minimal clinical evidence
- not commonly prescribed in immunocompromised patients
Steroids
- reserved for patients with resp compromise
Abx
- bacterial superinfection present in as many as 30%
- benzylpenicillin/penicillin V
Complications of glandular fever
Post-viral fatigue
- persistence of disabling fatigue, MSK pain or mood disturbance 6 months after initial infection
Malignancy
- associated with lymphomas (Burkitt’s, Hodgkins and T-cell)
- nasopharyngeal carcinoma
Guillain-Barre Syndrome
Encephalitis
- fever, seizures, unusual behaviour and gait disturbance
Splenic rupture
- can occur up to 8 weeks after presentation
- avoid contact sports for 4-6 weeks post infection
