ENT - Level 1

Question 1

Definition of otitis media?

Answer 1

• Middle ear inflammation

Question 2

Definition of recurrent otitis media with effusion?

Answer 2

• Recurrent ear infections – secretory otitis media (Glue ear)
  Middle ear effusion without the symptoms of acute otitis media

Question 3

How common is otitis media?

Answer 3

o Bacterial (most commonly)
 Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, streptococcus pyogenes
o Viral
 RSV, rhinovirus, adenovirus, influenza and parainfluenza

Question 4

Causative organisms of otitis media?

Answer 4

o Bacterial (most commonly)
 Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, streptococcus pyogenes
o Viral
 RSV, rhinovirus, adenovirus, influenza and parainfluenza

Question 5

Symptoms of otitis media?

Answer 5

• May follow URTI
• Symptoms
  o Rapid onset pain in the ear
  o Fever
  o Irritability
  o Vomiting
  o Deafness

Question 6

Signs of otitis media?

Answer 6

o Bright red and bulging with loss of normal light reflection
o Occasional acute perforation with pus in ear canal
o Look for swelling over mastoid – mastoiditis secondary

Question 7

Diagnosis of acute otitis media?

Answer 7

o Acute onset – earache, holding, tugging ear or non-specific symptoms
o Otoscopy – red, tallow or cloudy tympanic membrane with bulging and loss of normal landmarks, air fluid level behind tympanic membrane or perforation

Question 8

When to admit of otitis media for specialist assessment from primary care?

Answer 8

o Severe systemic infection
o Acute complications of otitis media (meningitis, mastoiditis, incracranial abscess, sinus thrombosis, facial nerve paralysis)
o Child <3 months with temperature >38

Question 9

Management of otitis media - general advice?

Answer 9

o	Analgesia (regular paracetamol and ibuprofen)
o	Most cases resolve spontaneously within 3 days but can be up to 1 week

Question 10

Management of otitis media - antibiotics?

Answer 10

o If very unwell, have symptoms and signs of illness or high risk:
 Immediate antibiotic
o For those who may benefit from antibiotics, consider delayed prescription, no prescription or immediate
 Amoxicillin for 5-7 days
 Can give clarithromycin or erythromycin if penicillin allergic

Question 11

Management of otitis media - if perforation?

Answer 11

o Follow up with ENT and do not swim

Question 12

Management of otitis media - if treatment failure?

Answer 12

o If not taken antibiotic – give prescription
 Amoxicillin for 5-7 days
 Can give clarithromycin or erythromycin if penicillin allergic
o If taken first-line antibiotics, give co-amoxiclav for 5-7 days
o If symptoms persist despite two courses of antibiotics – refer to ENT

Question 13

Management of otitis media if persistent symptoms - hearing loss with no pain or fever?

Answer 13

 Active observation for 6-12 weeks

 Two hearing tests using pure tone audiometry >3 months apart

Question 14

Management of otitis media if persistent symptoms - hearing loss with no pain or fever - when to refer?

Answer 14

o Hearing loss impacting child development
o Hearing loss >61dB
o Significant hearing loss on two occasions
o Tympanic membrane abnormal
o Foul-smelling discharge (cholesteatoma)
o Down’s syndrome or cleft palate

Question 15

Management of otitis media if persistent symptoms - hearing loss with no pain or fever - non-surgical and surgical management?

Answer 15

o Active observation for 3 months with regular audiology follow up
o Hearing aids
o Autoinflation

o Myringotomy with Grommet insertion, with or without adenoidectomy
 If persistent bilateral OME over 3 months with hearing in better ear <25-30dB averaged at 0.5, 1, 2 and 4 kHz or if affecting development
 Adenoidectomy only if frequent URTIs
 Follow up until grommets extruded and eardrum healed

Question 16

Management of otitis media if persistent symptoms - discharge from ear canal for 2 weeks?

Answer 16

 Refer to ENT assessment – given steroids and antibiotics and intensive cleaning of ear

Question 17

Complications of otitis media?

Answer 17

• Mastoiditis

- Meningitis

Question 18

Definition of pharyngitis?

Answer 18

local inflammation of oropharynx with enlarged and tender lymph nodes

Question 19

Definition of tonsilitis?

Answer 19

form of pharyngitis where there is intense inflammation of the tonsils, often with purulent exudate

Question 20

Definition of influenza?

Answer 20

acute respiratory illness caused by RNA Orthomyxoviridae viruses

Question 21

Epidemiology of URTIs?

Answer 21

• Highest incidence in children and young adults
• More common in winter
• URTI are 80% of respiratory infections

Question 22

Causative organisms of common cold (coryza)?

Answer 22

 Rhinovirus, coronaviruses, influenza virus, parainfluenza and RSV (however RSV usually causes acute bronchiolitis)
 Lasts 1 ½ weeks
 Common – adults 2-3x colds per year, children 5-6x colds per year

Question 23

Causative organisms of Pharyngitis/tonsilits?

Answer 23

 Adenoviruses, enteroviruses, rhinoviruses, influenza types A and B, parainfluenza, group A B-haemolytic streptococcus, HSV-1, EBV, Candida
 Non-infectious – physical irritation, hayfever, GORD, Kawasaki’s disease, oral mucositis
 Lasts 1 week

Question 24

Causative organisms of epiglottitis?

Answer 24

 Hib

Question 25

Causative organisms of influenza?

Answer 25

 Type A – frequent and more virulent, local outbreaks and epidemics  Type B – co-circulates with A during yearly outbreaks, less severe  Type C – mild/asymptomatic infection similar to common cold  Peak during winter months

Question 26

Symptoms of tonsillitis/pharyngitis?

Answer 26

``` o Fever (+/- febrile convulsions) o Painful throat o Exudate present in bacterial tonsillitis o Earache and nasal discharge o Difficulty feeding and drinking ```

Question 27

Symptoms of common cold?

Answer 27

o Sore throat o Nasal irritation, congestion, nasal discharge and sneezing o Cough o Hoarse voice o General malaise o Fever, myalgia and headache less common

Question 28

Symptoms of uncomplicated influenza?

Answer 28

 Coryza, cough, fever, Diarrhoea, headache, myalgia, malaise, sore throat, photophobia, conjunctivitis

Question 29

Symptoms of complicated influenza?

Answer 29

 Signs and symptoms requiring hospital admission, LRTIs, CNS involvement, exacerbation of underlying medical condition

Question 30

Assessment of tonsillitis/pharyngitis?

Answer 30

o Clinical examination – pus on tonsils indicates bacterial infection o Neck – think bacterial infection if tender lymphadenopathy o FeverPAIN score o Centor Criteria

Question 31

What is FeverPain score in tonsillitis?

Answer 31

```  Fever >38  Purulent (exudate on tonsils/pharyngeal)  Attend rapidly (<3 days)  Inflamed tonsils  No cough/coryza • Score 4 or 5 - Abx ```

Question 32

What is Centor Criteria in tonsillitis?

Answer 32

```  Tonsilllar exudate  Tender anterior cervical lymphadenopathy  Fever  Absence of cough • 3 or 4 needs Abx ```

Question 33

Investigations in influenza?

Answer 33

o Laboratory diagnosis for complicated influenza (in hospital) o Viral PCR o Alternatives – serology and culture

Question 34

Management of tonsillitis - hospital admission needed when?

Answer 34

 Breathing difficulty  Dehydration  Peri-tonsillar abscess or cellulitis  Sepsis

Question 35

Management of tonsillitis - if on DMARDs, carbimazole, chemotherapy, HIV, asplenia?

Answer 35

 Seek immediate advice |  FBC urgently

Question 36

Management of tonsillitis - general advice?

Answer 36

 Majority caused by viral infections  40% of symptoms resolve within 3 day and 85% within 1 week  Symptomatic relief • Keep hydrated • Paracetamol and ibuprofen • Avoid hot drinks – worsen pain  Children return to school after fever resolved and no longer feel unwell or after 24h of Abx

Question 37

Management of tonsillitis - Antibiotics?

Answer 37

 If positive culture or Centor criteria 3 or 4 or FeverPAIN 4 or 5  If FeverPAIN 2 or 3 – consider delayed prescription  Prescribe penicillin V (phenoxymethylpenicillin 500mg QDS) for 10 days  Alternatives: erythromycin or clarithromycin for 5 days  AVOID AMOXICILLIN AS CAUSES RASH IN EBV

Question 38

Management of tonsillitis - recurrent tonsillitis?

Answer 38

o If recurrent tonsillitis (>7 episodes per year for one year, >5 episodes per year for 2 years or >3 episodes per year for 3 years)  Refer to ENT for tonsillectomy advice

Question 39

Criteria for referral to ENT for tonsillectomy?

Answer 39

>7 episodes per year for one year >5 episodes per year for 2 years >3 episodes per year for 3 years

Question 40

Management of common cold - general advice?

Answer 40

o Self-limiting and symptoms peak around 2-3 days then decrease up to 1 week or 2 weeks for young children, cough may last for 3 weeks

Question 41

Management of common cold - symptomatic relief?

Answer 41

* Keep hydrated * Paracetamol and ibuprofen * Avoid hot drinks – worsen pain * Steam inhalation relieves congestion (or sitting in hot shower) * Intranasal decongestants, cough medicine available OTC

Question 42

Management of common cold - hygiene methods?

Answer 42

* Washing hands frequently with soap and water | * Avoid sharing towels

Question 43

Management of common cold - follow up?

Answer 43

 Come back if symptoms worsen or persist longer than 7/14 days

Question 44

Management of influenza - prevention with seasonal vaccine - when to give?

Answer 44

• All people >65 (trivalent) • All people 6m-65y if in following groups (quadrivalent): o Chronic respiratory illness  COPD, bronchiectasis, CF, ILD, pneumoconiosis, BPD, asthma needed ICS o Chronic heart disease  CHD, hypertension with cardiac complications, HF, regular medication for IHD o CKD (Stage 3-5), nephrotic syndrome, transplant o Chronic liver disease – cirrhosis, biliary atresia, chronic hepatitis o Neurological  Stroke/TIA, at risk of co-morbidity exacerbated by flu (CP, LD, PD, MS, MND, degenerative disease, polio) o DM type 1 and 2 needing OHA/insulin o Immunosuppressed  Chemotherapy, bone marrow transplant, HIV, systemic steroids (>1m of 20mg daily), myeloma, asplenia, or SCD o Pregnant women o BMI>40

Question 45

Management of influenza - symptomatic relief?

Answer 45

* Keep hydrated * Paracetamol and ibuprofen * Rest in bed * Stay off work/school until feel able to attend

Question 46

Management of influenza - antiviral therapy criteria?

Answer 46

o Antiviral (oral oseltamivir or inhaled zanamivir) if all of following apply:  National surveillance scheme indicate influenza circulating  Person at ‘high risk’ group • Aged >65, <6m or pregnant women • People with following conditions: • Asplenia, COPD, bronchiectasis, CF, ILD, pneumoconiosis, Asthma needing inhaled corticosteroids • HF, CHD, IHD • CKD (Stage 3-5), chronic liver disease • Stroke/TIA • DM • Immunosuppressed – chemotherapy, bone marrow transplant, HIV, systemic steroids (>1m of 20mg daily), myeloma • BMI >40  Person can start treatment within 48 hours of onset of symptoms (36 with zanamivir with children)

Question 47

Management of influenza - follow up?

Answer 47

 Within 1 weeks if >65 or <6m to confirm improving |  After 1 week if not improving

Question 48

Management of influenza - admission to hospital if?

Answer 48

 Complication – pneumonia  High risk of complications  <2 years and at risk group  Febrile seizure

Question 49

Management of influenza - post-exposure prophylaxis given when and what?

Answer 49

• National surveillance scheme indicates influenza circulating • Person exposed (in same household or residential setting) • At risk group and: o Not vaccinated since previous season o Vaccination not well-matched to circulating scheme o <14 days between vaccination and date of contact • Person can start treatment within 48 hours of onset of symptoms (36 with zanamivir with children)  Oral oseltamivir or inhaled zanamivir for 10 days

Question 50

Complications of tonsilitis/cold?

Answer 50

o Otitis Media o Sinusitis o Peritonsillar abscess (quinsy) o Para-pharyngeal abscess

Question 51

Complications of influenza?

Answer 51

``` o Bronchitis o Exacerbation of asthma or COPD o Otitis media o Pneumonia o Sinusitis o Myocarditis, pericarditis o Febrile convulsions o Myalgia, rhabdomyolysis o GBS o In pregnancy – preterm labour and low birth weight ```

Question 52

Neck lumps - key features of reactive lymphadenopathy?

Answer 52

Most common cause History of localised infection or generalised viral illness

Question 53

Neck lumps - key features of lymphoma?

Answer 53

Rubbery, painless lymphadenopathy Pain whilst drinking alcohol (rare) Night sweats and splenomegaly

Question 54

Neck lumps - key features of thyroid goitres/lumps

Answer 54

Symptomatic hypo/hyperthyroid Moves upward on swallowing

Question 55

Neck lumps - key features of thyroglossal cyst

Answer 55

Common in patients <20 Midline between thyroid isthmus and hyoid bone Moves upwards with tongue protrusion Painful if infected

Question 56

Neck lumps - key features of pharyngeal pouch

Answer 56

Older men Posteromedial herniation between thyropharyngeal and cricopharyngeus muscles If large midline lump in neck that gurgles on palpation Symptoms - dysphagia, regurgitation, aspiration, chronic cough

Question 57

Neck lumps - key features of cystic hydroma?

Answer 57

Congenital lymphatic lesion Left side neck Most evident at birth but 90% by 2

Question 58

Neck lumps - key features of branchial cyst

Answer 58

Oval mobile cystic mass between sternocleidomastoid muscle and pharynx Presents in early adulthood

Question 59

Key features of salivary gland stones (sialolithiasis)

Answer 59

primarily affect the submandibular glands but are also seen in the parotid and sublingual glands Age 50-60 Majority calcium phosphate stones Symptoms - Pain and swelling of gland on eating or chewing. Resolve after mealtimes Management - conservative management -well hydrated, NSAIDs for pain If recurrent then refer to ENT