ENT: Tonsillitis Flashcards
What are the 3 most common viral causes of a sore throat?
1) Rhinovirus (most common)
2) Coronavirus
3) Parainfluenza virus
Is tonsillitis usually viral or bacterial?
Viral
What is the most common cause of bacterial tonsillitis?
Group A Strep (Strep. pyogenes)
What is the most common organsim causing otitis media and rhinosinusitis?
Streptococcus pneumoniae.
What is the most common alternative bacterial cause of tonsillitis (i.e. not GAS)?
Streptococcus pneumoniae.
What Abx can bacterial tonsillitis caused by GAS (S. pyogenes) be treated by?
penicillin V (phenoxymethylpenicillin)
What is the ring of lymphoid tissue found in the throat called?
Waldeyer’s Tonsillar Ring –> made up of the tonsils, adenoids, and other lymphoid tissue.
Acute tonsillitis is the inflammatory infection of which tonsils?
Palatine tonsils
Typical features of acute tonsilitis?
- Sore throat
- Fever
- Dysphagia
- Nasal congestion, headache, earache, cough (if viral)
May present with non-specific features in childre –> fever, poor oral intake, headache, vomiting or even abdominal pain.
Does the presence of a cough indicate a viral or bacterial cause of tonsillitis?
Viral (if no cough is present, this is more likely bacterial cause).
What may you see on examination of the pharynx in acute tonsillitis?
- Severely inflamed tonsils
- Painfully enlarged anterior cervical lymph nodes
- Purulent tonsils (suggestive of bacterial cause)
When should you NOT do an examination of the pharynx in tonsillitis?
If epiglottitis suspected.
Give some additional features that may be suggestive of epiglottitis
- A young child
- A muffled voice
- Excessive drooling and pooling of saliva.
What should you do if epiglottitis is suspected?
Call for an anaesthetist and an ENT surgeon!
What 3 things should your exam consist of in tonsillitis?
1) Exam of pharynx (if epiglottitis is not suspected)
2) Otoscopy: to visualise tympanic membranes
3) Palpate for any cervical lymphadenopathy
What is the Centor criteria for?
The Centor criteria can be used to estimate the probability that tonsillitis is due to a bacteria infection, and will benefit from antibiotics.
What Centor score indicates that it is appropriate to offer Abx?
A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis –> it is appropriate to offer antibiotics.
What makes up the Centor criteria?
A point is given if each of the following features are present:
1) Fever over 38ºC
2) Tonsillar exudates
3) Absence of cough
4) Tender anterior cervical lymph nodes (lymphadenopathy)
What is an alternative to the Centor criteria?
The FeverPAIN score
Acute tonsillitis is usually a clinical diagnosis.
When may investigations be required?
In patients on immunosuppression, very old or young, with severe symptoms.
What is the 1st line investigation in acute tonsillitis in those who require it?
A rapid antigen test for GAS, followed by a throat culture.
What does management of most cases of tonsillitis involve?
Reassure – symptoms can last for around 1 week, but most people get better within this time without treatment.
Paracetamol or ibuprofen – for pain or fever.
Fluids – adequate intake maintained.
Are Abx routinely indicated in tonsillitis?
No
if antibiotics are indicated in tonsillitis, what is 1st line?
phenoxymethylpenicillin (or erythromycin if penicillin allergic) for 7-10 days
Give some indications for Abx in tonsillitis
- features of marked systemic upset secondary to the acute sore throat
- unilateral peritonsillitis
- a history of rheumatic fever
- an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
- patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
What does the feverPAIN criteria consist of?
1 point for each (maximum score of 5)
1) Fever over 38°C.
2) Purulence (pharyngeal/tonsillar exudate).
3) Attend rapidly (3 days or less)
4) Severely Inflamed tonsils
5) No cough or coryza
What does a feverPAIN score of 4-5 indicate?
62-65% likelihood of isolating Streptococci (i.e. bacterial) - consider Abx
What are some potential complications of acute tonsillitis?
1) Acute otitis media
2) Peritonsillar abscess (quinsy) or neck abscess
3) Acute sinusitis
Rare –> scarlet fever, acute rheumatic fever, post-streptococcal glomerulonephritis:
How does post-streptococcal glomerulonephritis present?
Haematuria, oedema, vomiting and anorexia.
The indications for tonsillectomy are controversial.
When should surgery be considered (according to NICE)?
If the person meets all of the following criteria:
1) sore throats are due to tonsillitis (i.e. not recurrent URTI)
2) the person has 5 or more episodes of sore throat per year
3) symptoms have been occurring for at least a year
4) the episodes of sore throat are disabling and prevent normal functioning
Other indications:
- Recurrent tonsillar abscesses (2 episodes)
- Enlarged tonsils causing difficulty breathing, swallowing or snoring
Complications of a tonsillectomy can be 1ary or 2ary.
What is the difference?
1ary: <24 hpurs
2ary: 24 hours to 10 days
How may pain change after a tonsillectomy?
The pain may increase for up to 6 days following a tonsillectomy.
What is a feared complication following tonsillectomy?
Haemorrhage
When does 1ary (or reactionary) haemorrhage most commonly occur following a tonsillectomy?
First 6-8 hours after surgery
Management of a 1ary haemorrhage following a tonsillectomy?
Immediate return to theatre.
What is 1ary haemorrhage following a tonsillectomy most commonly associated with?
Inadequate homeostasis
What is 2ary haemorrhage following a tonsillectomy most often associated with?
Wound infection
What does management of 2ary haemorrhage following a tonsillectomy often involve?
Treatment is usually with admission and antibiotics.
Severe bleeding may require surgery.
What is a peritonsillar abscess (quinsy)?
A serious complication of tonsillitis that requires prompt diagnosis and treatment.
It is a collection of pus in the tissue surrounding the tonsils, usually caused by bacterial infection.
What are peritonsillar abscesses usually a complication of?
Untreated or partially treated tonsillitis, although it can arise without tonsillitis.
Age of incidence of quinsy vs tonsillitis?
Quinsy - can occur just as frequently in teenagers and young adults as it does in children
Tonsillitis - much more common in children
Clinical features of a quinsy?
- Severe sore throat
- Difficulty swallowing
- Fever
- Referred ear pain
- Trismus
- Change in voice due to pharyngeal swelling: “hot potato voice”
What is trismus?
Refers to when the patient is unable to open their mouth
What is the most common organism causing a quinsy?
GAS (S. pyogenes)
What are the 3 most common organisms causing a quinsy?
1) GAS (most common)
2) Staph. aureus
3) H. influenzae
Management of a quinsy?
Refer to ENT –> incision & drainage of abscess under GA.
Abx before & after surgery.
What is typical Abx of choice in quinsy?
Broad spectrum e.g. co-amoxiclav
What is otitis media (OM)?
A common infection of the middle ear - found predominantly in children under the age of four.
What is OM often preceded by?
A viral URTI
What is the most common bacterial cause of OM?
Strep. pneumoniae
What are some intrinsic factors that may predispose an individual to develop OM?
- Age <4
- Atopic predisposition
- Immunosuppression
- Conditions affecting ciliary motility: CF, primary ciliary dyskinesia, Kartagener’s syndrome
What are 3 conditions affecting ciliary motility that predispose to OM?
1) CF
2) Primary ciliary dyskinesia
3) Kartagener’s syndrome
What are some extrinsic factors that predipose to OM?
- Passive smoking
- Not receiving pneumococcal vaccination
- Daycare
- Bottle feeding
- Use of a dummy
- Low socioeconomic status
Not receiving which vaccination can predispose to OM?
pneumococcal
Why can bottle feeding predispose to OM?
1) The strong swallow required to feed from a breast induces a sizeable negative pressure in the infants oral cavity allowing eustachian tube insufflation. Bottle feeding relies more on gravity from the bottle, and less negative pressure is required.
2) Breast milk provides maternal antibodies against common OM pathogens.
Pathophysiology of OM?
OM occurs secondary to oedema and narrowing of the eustachian tube.
An oedematous eustachian tube prevents the middle ear from draining, predisposing it to the colonisation of bacteria.
What causes earache in OM?
The eustachian tube serves to equalise pressure in the middle ear, when the tube is blocked this cannot happen.
A low pressure in the middle is the primary cause of earache.
What will relieve earache in OM?
Rupture of the TM will resolve the pressure differential and relieve pain.
Why are children predisposed to OM? (3 reasons)
1) Their eustachian tubes are narrower and more prone to blockage
2) Their eustachian tubes are more horizontal, inhibiting drainage
3) Children have less developed immune systems, so are more prone to URTIs (causing OM)
95% of bacteria isolated from infected middle ears are which three pathogens?
1) Streptococcus pneumoniae
2) Moraxella catarrhalis
3) Haemophilus influenzae
Clinical features of OM?
1) otalgia (some children may tug or rub their ear)
2) fever (50%)
3) hearing loss
4) recent viral URTI symptoms are common (e.g. coryza)
5) ear discharge: if the tympanic membrane perforates
What should examination in OM involve?
1) Otoscopy of BOTH ears
2) Examination of throat
How should a normal tympanic membrane appear on otoscopy?
“Pearly-grey”, translucent and slightly shiny.
You should be able to visualise the malleus through the membrane and a cone of light reflecting the light of the otoscope.
Possible otoscopy findings in OM?
1) bulging red tympanic membrane –> loss of light reflex
2) opacification or erythema of the tympanic membrane
3) perforation with purulent otorrhoea
4) decreased mobility if using a pneumatic otoscope
OM is a clinical diagnosis.
However, you must first exclude what serious complications?
1) Mastoiditis
2) Meningitis
3) Intracranial abscess
Whilst guidelines vary, the majority use the following criteria to diagnose otitis media:
1) acute onset of symptoms: otalgia or ear tugging
2) presence of a middle ear effusion: bulging of the tympanic membrane, or otorrhoea, or decreased mobility on pneumatic otoscopy
3) inflammation of the tympanic membrane i.e. erythema
Give 5 differentials for OM
1) Impacted cerumen
2) Otitis externa
3) Foreign body
4) Cholesteatoma
5) Mastoiditis
Are Abx always indicated in OM?
No - most cases of OM will self resolve without antibiotics.
Management is conservative and focussed upon managing symptoms with simple analgesia.
Note - can give a delayed prescription of Abx to take in 3 days if symptoms don’t improve.
In which groups with OM is it recommended to prescribe Abx?
1) Children under the age of two with bilateral OM
2) Children younger than 3 months with a temperature over 38ºC
3) OM with ear discharge
4) Those who are systemically unwell
5) Those at high risk of complication
1st line Abx in OM?
Amoxicillin (5-7 day course)
Erythromycin or clarithromycin if penicillin allergic.
What are some complications of OM?
1) Acute and chronic otitis media with effusion (glue ear)
2) Chronic suppurative OM
3) Tympanic membrane perforation
4) Hearing loss
5) Tinnitus
6) Mastoiditis
7) Bacterial meningitis
8) Intracranial abscess
9) Facial paralysis
Mastoiditis is a serious complication of OM.
What is the management?
IV Abx
In some cases surgery is necessary e.g. myringotomy & mastoidectomy
What does myringotomy involve?
surgically draining the middle ear
What % of acute OM will progress to chronic OM?
8%
Tympanic membrane perforation is a common occurrence in OM and will ordinarily heal within a few weeks.
What advice should you give?
Patients should be advised to avoid swimming and to be careful when in the shower.
Why is it important to assess the site of tympanic membrane perforation in OM?
As perforations in the upper portion of the drum are more likely to lead to mastoiditis and will require closer monitoring.
When is hearing loss as a complication of OM more common?
With recurrent OM
How can OM lead to facial paralysis?
The corda tympani branch of the facial nerve runs through the middle ear.
What is glue ear?
OM with effusion –> when fluid accumulates in the middle ear.
What is usually the presenting feature of glue ear?
Hearing loss
What is the commonest cause of conductive hearing loss and elective surgery in childhood?
Glue ear
features of glue ear?
- Hearing loss
- 2ary problems: speech and language delay, behavioural or balance problems
Management of glue ear?
1) Watchful waiting: most cases resolve spontaneously within 3 months without interventions
2) Myringotomy and grommet insertion
What investigation should children with glue ear be referred for?
Audiometry to help establish the diagnosis and extent of hearing loss.
When may surgical intervention be considered in glue ear?
If conservative management fails or if there are complications such as persistent hearing loss or recurrent acute otitis media episodes.
What are grommets?
Grommets are tiny tubes inserted into the tympanic membrane by an ENT surgeon.
This allows fluid from the middle ear to drain through the tympanic membrane to the ear canal.
How long do grommets typically last?
Grommets typically fall out spontaneously after 6-12 months.
what complications should children with grommets be monitored for?
Otorrhoea, tympanic membrane perforation or scarring.
What is chronic suppurative otitis media (CSOM)?
Persistent inflammation of the middle ear that results in the discharge of pus from the ear.
Caused by bacterial or fungal infections.
Where is CSOM more common?
In developing countries
What are some risk factors for CSOM?
Poor hygiene, malnutrition, and exposure to polluted environments.
Typical features of CSOM?
- Recurrent episodes of otorrhoea that may be purulent, mucoid or serous (NOT typically not associated with otalgia or fever)
- Hearing loss
- Itching or irritation in the ear canal
- Perforation of the tympanic membran
