ENT: Throat & Salivary Gland Problems

Question 1

What is the most common cause of tonsillitis?

State common causes of bacterial tonsillitis

Answer 1

• Tonsillitis most commonly caused by viral infection
• Can be caused by bacteria:
  
  • Most common= Streptococcus pyogenes
  • Second most common= Streptococcus pneumoniae
  • Others= Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus

Question 2

Remind yourself of Waldeyer’s ring

Answer 2

Question 3

Describe typical presentation of tonsillitis

Answer 3

• Sore throat
• Fever (>38)
• Odynophagia
• Red inflamed tonsils +/- exudates
• +/- anterior cervical lymphadenopathy

Question 4

Outline the Centor criteria

Answer 4

Estimates probability that tonsillitis due to bacterial infection and will benefit from abx. Score of 3 or more gives 40-60% probability of bacterial tonsillitis and it is therefore appropriate to give abx.

• Fever over 38 degrees
• Tonsillar exudates
• Absence of cough
• Tender anterior cervical lymph nodes

Question 5

Outline the FeverPAIN score

Answer 5

Estimates probability that tonsillitis due to bacterial infection and will benefit from abx. Score of 2-3 gives 34-40% probability and a score of 4-5 gives a 62-65% probability of bacterial tonsillitis and it is therefore appropriate to give abx.

• Fever during previous 24hrs
• Purulent tonsils
• Attended within 3 days of onset of symptoms
• Inflamed tonsils
• No cough or coryza

Question 6

Which pts with tonsillitis would you consider admitting?

Answer 6

Consider admission if:

• Immunocompromised
• Systemically unwell
• Dehydrated
• Stridor
• Respiratory distress
• Evidence of peritonsillar abscess or cellulitis

Question 7

Discuss the management of tonsillitis (acute, not asking about management of recurrent)

Answer 7

• Reassurance and self-care advice e.g. simple analgesia, adequate fluid intake, salt water gargling and local anaesthetic throat spray may help pain
• Safety netting (if not improved after 3 days or fever rises >38.3)
• Consider antibiotics if Centor ≥3 or FeverPAIN ≥4 or if at high risk of more severe infection (e.g. immunocompromised, young infants, significant comorbidities, hx of rheumatic fever). Can also consider delayted prescription for if symptoms don’t improve in a few days.
  
  • Phenoxymethylpenicillin for 10 days
  • If penicillin allergic, clarithromycin

Question 8

State some potential complications of tonsillitis

Answer 8

• Peritonsillar abscess (quinsy)
• Otitis media
• Scarlet fever
• Rheumatic fever
• Post-streptococcal glomerulonephritis
• Post-streptococcal reactive arthritis

Question 9

Discuss the SIGN guidelines for tonsillectomy

Answer 9

• Bases on number of epsiodes:
  
  • ≥ 7 in 1 year
  • ≥ 5 per year for 2 years
  • ≥ 3 per year for 3 years
• Recurrent tonsillar abscesses (≥ 2 episodes)
• Enlarged tonsils causing difficulty breathing, swallowing or snoring (in children often do adenotonsillectomy for this)
• Recurrent febrile convulsions secondary to episodes of tonsillitis

Question 10

Tonsillectomy is usually done as a day case procedure; true or false?

Answer 10

Yes, performed under GA as a day case; after period of observation, in which pt has eaten and drank, can usually go home (unless comorbidities, significant sleep apnoea, intra-operative complications etc…)

Question 11

State some potential complications of tonsillectomy

Answer 11

• Sore throat where the tonsillar tissue has been removed (this can last 2 weeks)
• Damage to teeth
• Infection
• Post-tonsillectomy bleeding
• Risks associated with a general anaesthetic

**Remember, pts who had tonsillectomy can still get sore throat from other causes after operation

Question 12

In surgery, what is meant by a primary haemorrhage and what is meant by a secondary haemorrhage?

Answer 12

• Primary: within first 24hrs
• Secondary: after first 24hrs

Question 13

Post-tonsillectomy bleeding can be severe, and in rare cases, life threatening; true or false?

Answer 13

True; can result in aspiration of blood

Significant bleeding occurs in up to 5%

Question 14

Discuss the management of post-tonsillectomy bleeding (include immediate & definitive)

Answer 14

Immediate

As with any acutely unwell/deteriorating pt do A-E along with:

• Calling ENT registrar early
• Keep pt calm & sit them up encouraging them to spit blood out rather than swallowing
• IV access & take bloods (FBC, clotting screen, G&S and crossmatch)
• Make them NBM (in case anaesthetic & operation needed)
• Analgesia
• Ice pack for back of neck
• IV fluids (resuscitation or maintenance) if required
• If severe bleeding or airway compromise, call an anaesthetist as intubation may be required
• If severe, alert emergency theatre/anaesthetist that the patient may need an urgent arrest of post-tonsillectomy bleed

More definitive

Going back to theatre is the definitive option, however can try the following for less severe bleeds beforehand:

• Hydrogen peroxide gargle
• Adrenalin soaked swab applied topically

Pts presenting with post-tonsillectomy bleed, even if not large, most likely admitted for observation

Question 15

What is quinsy (peritonsillar abscess)?

Answer 15

Peritonsillar abscess is a complication of acute tonsillitis, where a collection of pus forms in the peritonsillar space. This pushes the affected tonsil inferomedially into the oropharyngeal space.

Question 16

Who does quinsy occur in (age)?

Answer 16

Unlike tonsillitis, which is much more common in children, quinsy can occur just as frequently in teenagers & adults

Question 17

What is the most common causative organism of quinsy?

Answer 17

• Streptococcus pyogenes
• Others: Staphylococcus aureus, Haemophilus influenza

Question 18

Describe typical presentation of quinsy

Answer 18

Patients present with similar symptoms to tonsillitis:

• Sore throat
• Painful swallowing
• Fever
• Neck pain
• Referred ear pain
• Swollen tender lymph nodes

Additional symptoms that can indicate a peritonsillar abscess include:

• Trismus (pt unable to open their mouth)
• Hot potato voice (change in voice due to the pharyngeal swelling)
• Swelling and erythema in the area beside the tonsils
• Uvula deviation

Question 19

Discuss the management of quinsy

Answer 19

Refer to ENT for assessment & management:

• Aspiration or incision and drainage
• IV antibiotics (e.g. co-amoxiclav)
• Some surgeons also give single dose of dexamethasone

Not all patients need to be admitted:

• A good principle: admit anyone unable to swallow enough fluid to stay hydrated (IV access, fluids, blood etc…)
• Patients with a peritonsillar abscess can be discharged after drainage, some intravenous antibiotics and a few hours’ observation if they are well and able to swallow

Other aspects of management:

• Analgesia (paracetamol, ibuprofen, topical spray)
• Advise to sleep upright if stertor
• Consider tonsillectomy (see previous FC)

Question 20

What is obstructive sleep apnoea?

Answer 20

Intermittent collapse of pharyngeal airway during sleep causing apnoeic episodes

Question 21

State risk factors for OSA

Answer 21

• Middle aged
• Male
• Obesity
• Alcohol
• Smoking
• Macroglossia (i.e. in acromegaly, hypothyroidism)
• Marfan’s syndrome

Question 22

State some features of OSA

Answer 22

• Episodes of apnoea (reported by partner)
• Snoring
• Morning headache
• Daytime sleepiness/waking up unrefreshed
• Concentration problems

Severe cases can cause hypertension, heart failure and increased risk of MI and stroke

Question 23

What can be used to assess symptoms of sleepiness associated with OSA?

Answer 23

Epworth Sleepiness Scale

Question 24

What questionnaire can be used to classify anaesthetic risk in pts with OSA?

Answer 24

STOP-Bang

Question 25

Discuss the management of OSA

Answer 25

Pts with suspected OSA require referral to ENT or specialist sleep clinic to perform sleep studies/polysomnography. Management includes: * Correcting any reversible risk factors *(e.g. stop smoking, stop drinking alcohol, lose weight)* * Intra-oral devices/mandibular advancement devices * Moderate-severe: CPAP * Surgery to reconstruct soft palate and jaw (e.g. uvulopalatopharyngoplasty) * Informing DVLA *\*\*If can't do polysomnography can do overnight pulse oximetry*

Question 26

State some potential complications of OSA

Answer 26

* Compensated respiratory acidosis * Cardiovascular disease * Hypertension * MI * Heart failure * Cognitive dysfunction * Daytime somnolence * Depression

Question 27

What happens to BP with every arousal in OSA? What happens to daytime BP in OSA?

Answer 27

* With every arousal there is rise in BP (often over 50mmHg) * Rise in daytime BP

Question 28

Discuss the pathophysiology of OSA

Answer 28

* When you sleep all muscles relax (including pharyngeal dilators which are responsible for airway patency) * Since pharyngeal dilators relax, some loss of tone and hence narrowing is normal in sleep * Excessive narrowing occurs in OSA and this may be due to: * An already small pharyngeal size undergoing normal degree of muscle relaxation * External pressure from increased neck fat or muscle bulk * Large tonsils * Craniofacial abnormalities * Excessive narrowing of normal pharyngeal size * Neuromuscular disease with pharyngeal involvement e.g. MND, stroke * Muscle relaxants e.g. alcohol, sedatives * Increasing age

Question 29

For glossitis, discuss: * What it is * Appearance * Causes * Management

Answer 29

* Inflammation of tongue * Erythematous, swollen tongue with smooth appearance due to atrophy of papillae * Causes: * Iron deficiency anaemia * B12 deficiency * Folate deficiency * Coeliac disease * Injury or irritant exposure * Management: treat underlying cause

Question 30

For angioedema, discuss: * What it is * Appearance * Causes (top 3)

Answer 30

* Fluid accumulation in deep dermis and subcutaneous tissue; can affect limbs, face, lips, tongue etc… * Swollen tissue * Causes: * Allergic reaction * ACE inhibitors * C1 esterase inhibitor deficiency (hereditary angioedema)

Question 31

For oral candidiasis, discuss: * What it is * Appearance * Risk factors * Management

Answer 31

* Oral thrush= overgrowth of candida (usually candida albicans) in mouth * White spots or patches on tongue that can be scraped off * Risk factors: * Inhaled corticosteroids * Antibiotics * Diabetes * Immunodeficiency e.g. HIV * Smoking * Management: * Miconazole gel * Nystatin suspension * Fluconazole tablets (severe or recurrent)

Question 32

For geographic tongue, discuss: * What it is & appearance * Causes * Management

Answer 32

* Inflammatory condition where there are irregularly shaped patches of lost epithelium and papillae *(resembling a map with countries and oceans).* Tends to relapse and remit * Cause is unknown but can be related to: * Stress * Mental illness * Psoriasis * Atopy * Diabetes * Benign with no harmful effects so doesn't usually require treatment. Symptoms like burning or discomfort can be treated with topical steroids or antihistamines

Question 33

For strawberry tongue, discuss: * What it is * Appearance * Causes (2 key ones)

Answer 33

* Tongue is **erythematous, swollen** and **papillae become enlarged, white & prominent** * Causes: * Scarlet fever * Kawasaki disease

Question 34

For black hairy tongue, discuss: * What it is * Appearance * Cause * Management

Answer 34

* Condition due to decreased shedding/desquamation of keratin from tongue's surface * Papillae elongate, so look like hairs. Bacteria & food can cause dark pigmentation of the papillae (but can also be other colours e.g. brown, green etc..) * Causes: * Dehydration * Dry mouth * Poor oral hygiene * Smoking * Head & neck radiation * Management: * Tongue scraping/swab to exclude candida * Adequate hydration * Gentle brushing of tongue * Stop smoking

Question 35

Discuss, for leukoplakia: * What it is/appearance * Management

Answer 35

* Pre-cancerous conditions characterised by white patches in mouth (tongue or inside of cheek) that cannot be scraped off * Management: * NICE CKS says urgent referral to dentist * Stop smoking * Reduce alcohol intake * Monitoring * Potentially laser removal or surgical excision

Question 36

For erythroplakia, discuss: * What is is/appearance * Management

Answer 36

* Pre-cancerous conditions characterised by red patches on tongue (Erythroleukoplakia is a mixture or red & white patches) * NICE CKS says urgent referral to dentist

Question 37

For lichen planus, discuss: * What it is * Appearance on skin * Appearance on mucous membranes * Management

Answer 37

* **Autoimmune condition causing localised chronic inflammation** of the skin * Appearance on skin: shiny, purplish, flat topped raised areas with white lines across surface (Wickham's striae) * Appearance on mucous membranes (usually mouth): * Reticular: net-like web of white lines (Wickham's striae) * Erosive: bright red area * Plaques: larger areas of white mucosa * Management: * Good oral hygiene * Stop smoking * Topical steroids

Question 38

For gingivitis, discuss: * What it is * Presentation * Risk factors * Management

Answer 38

* **Inflammation of gums** * Presentation: swollen gums, bleeding after brushing, painful gums, halitosis * Risk factors: * Plaque * Smoking * Diabetes * Malnutrition * Stress * Patients with gingivitis will be **managed by a dentist**. Treatment involves: * Good oral hygiene * Stopping smoking * Dental hygienist treatment to remove plaque and tartar * Chlorhexidine mouth wash * Antibiotics for acute necrotising ulcerative gingivitis (e.g., metronidazole) * Dental surgery if required

Question 39

For gingival hyperplasia, discuss: * What it is * Causes

Answer 39

* Abnormal growth of gums * Causes: * Gingivitis * Pregnancy * Vitamin C deficiency (scurvy) * Acute myeloid leukaemia * Medications, particularly calcium channel blockers, phenytoin and ciclosporin

Question 40

For acute necrotizing ulcerative gingivitis, discuss: * Presentation * Management

Answer 40

* Painful bleeding gums with halitosis & punched out ulcers on gums * Management: * Refer to dentist and in meantime: * Abx (PO metronidazole or amoxicillin 3/7) * Chlorhexidine mouthwash * Simple analgesia

Question 41

For aphthous ulcers, discuss: * Appearance * Which diseases can be associated with * Management

Answer 41

* Well circumscribed, punched out, white appearance, painful * Most have no underlying cause but associated diseases include: * IBD * Coeliac disease * Vit deficiencies (e.g., iron, B12, folate and vitamin D) * HIV * Behçet disease * Mangement: * Unexplained ulceration lasting \>3/52 refer via 2WW for suspected oral cancer * Usually heal in two weeks but can offer: * Topical treatments e.g. bonjela, difflam spray, lidocaine * Topical steroids if severe e.g. hydrocortisone buccal tablets

Question 42

What duct connects parotid gland with oral cavity? What duct connects submandibular gland with oral cavity?

Answer 42

* Parotid= Stenson * Submandibular= Wharton

Question 43

Which gland is Sialolithiasis most common in? What features in history would point to Sialolithiasis? What investigations would you do? Discuss the management

Answer 43

* Most common in submandibular * Colicky pain & post-prandial swelling of gland * Sialography (can also do plain x-ray as stones radio-opaque) * If impact distally may be able to remove orally but otherwise may require gland excision * Potential complication= if become infected → Ludwig's angina

Question 44

State some causes of hoarseness of voice

Answer 44

* viral illness leading to laryngitis * hypothyroidism * gastro-oesophageal reflux (causing irritation of throat) * laryngeal cancer * lung cancer * Papilloma's/polyps on vocal cords * growths on vocal cords * Nodules *(can develop if overuse of voice)* * Polyps *(often associated with smoking)* * Papilloma's * paralysis of vocal cords (recurrent laryngeal nerve damage)

Question 45

Remind yourself of 2WW pathway for laryngeal cancer

Answer 45

Aged 45yrs and over with: * Persistent unexplained hoarseness * Unexplained lump in neck

Question 46

Discuss the management of intermittent hoarseness of voice

Answer 46

In most cases this will settle by itself. To help relieve the symptoms one can: * rest the voice (but don’t resort to whispering which can make matters worse). * drink plenty of fluids (avoid too many fizzy drinks). * avoid alcohol. * avoid cigarette smoke. * take Antacids e.g Gaviscon if you get a build-up of acid in the throat.

Question 47

What are some options for the management of persistent hoarseness of voice?

Answer 47

Depends on underlying cause: * Simple advice as on other FC * Voice therapy * Radiotherapy * Surgery