ENT, URTIs and LRTIs

Question 1

how does the length of time someone presents with sinusitis for help in determining if bacterial or viral cause?

Answer 1

viral disease-lasts less than 10 days

worsening symptoms after 5 days, or symptoms extending beyond 10 days suggests bacterial infection

Question 2

pathophysiology of croup?

Answer 2

croup=acute laryngotracheobronchitis
viral URTI causing nasopharyngeal inflammation that may spread to larynx and trachea, causing subglottal inflammation and oedema and airway compromise.
vocal cord movement impaired producing barking cough and hoarse voice.
typically affects children from 6mnths to 5 years of age, most commonly incidence in children aged 2.

Question 3

why is there controversy over diagnosing sinusitis in children?

Answer 3

paranasal sinuses poorly developed in children, radiographic evidence only visible from about 9 yrs of age
but recognised that can be diagnosed in those over 1 year old, with symptoms of irritability, lethargy, snoring, mouth breathing, feeding difficulty and hyponasal speech.

Question 4

management of most patients with acute sinusitis in the GP setting?

Answer 4

most commonly viral, so can be reassured that similar to a cold but takes longer to resolve-around 2 and a half weeks
advise ways in which symptoms can be relieved e.g. paracetamol/ibuprofen/codeine
intranasal decongestant-vasoconstrictor, but found don’t really help
warm face packs
nasal irrigation with warm saline solution
plenty of rest and fluids
if been for more than 2 weeks, may consider nasal steroid e.g. beconase
Abx may be consider if prolonged or severe, may be of small benefit
if symptoms persist for more than 3 months, presence of red flags or frequent recurrent episodes then r/f to ENT

Question 5

ear problem presentation, what do we want to know?

Answer 5

pain
discharge
deafness
tinnitus
vertigo-consider benign paroxysmal positional vertigo-due to otoliths-calcium carbonate detachments, in inner ear, menieres disease, labyrinthitis and vestibular neuronitis

Question 6

presentation of post-nasal drip?

Answer 6

persistent nasal discharge
persistent nasal blockage
recurrent need to clear throat
chronic cough-more than 8 weeks, worse on rising on a morning

Question 7

what criteria are used to help determine need for Abx in presentation of tonsillitis?

Answer 7

centor criteria:
painful anterior cervical lymphadenopathy
fever
absence of cough-systemic feature more likely of viral infection
enlarged tonsils with exudates-white/yellow

3/4 features likely bacterial infection, recommend prescribing antibiotics

Question 8

what antibiotics are prescribed for suspected bacterial tonsillitis?

Answer 8

penicillin 10 DAY COURSE
500mg QDS (2x250mg QDS) in adults
if child under age of 1, 62.5mg 
if child 1-5yrs, 125mg liquid bottle
child over 5yrs=250mg

Question 9

ENT red flags?

Answer 9

anything unilateral: unilateral nasal polyps, unilateral epistaxis, unilateral tinnitus-if persistent r/f to ENT for MRI-look for acoustic neuroma, unilateral ET dysfunction, persistent unilateral nasal discharge
swelling behind ear
ear chondritis or perichondritis
non-healing oral ulcers

Question 10

what do we want to know regarding epistaxis?

Answer 10

unilateral or bilateral, unilateral red flag
blood or clots, how much
frequency, duration
URT symptoms e.g. runny nose, eye watering, hoarse voice, ear pain and recurrent ear infections-?wegener's, sneezing?
headaches and vomiting-?HTN
nose picking?
FB?
DH e.g. aspirin, warfarin

Question 11

tment of mild epistaxis?

Answer 11

naseptin-moisturising function in epistaxis as commonly result of dry skin/dehydration in little’s area/kiesselbach’s plexus due to drying effect of inspiratory current, anastomosis of anterior ethmoidal artery from opthalmic from ICA, sphenopalatine artery-terminal branch of maxillary from ECA, greater palatine artery-from maxillary and septal branch of superior labial artery from facial.
naseptin should be rubbed in by massage nose from the outside.

Question 12

presentation of otitis media with perforation?

Answer 12

excruciating ear pain then resolution with bloody discharge noted in the ear
perforation should be covered with Abx-5-7 day course of amoxicillin, then r/v in 2 wks time to check for TM healing, perforation marginal heals less well and may need ENT r/f

Question 13

another name for external ear boil-very painful as limited SC tissue for expansion?

Answer 13

furuncle (furunculosis)

Question 14

presentation of viral otitis media?

Answer 14

more systemic features, and those of recent URTI-malaise, runny nose, sore throat, pyrexia, headache
if no TM perforation, don’t require Abx treatment

Question 15

bacterial causes of otitis media?

Answer 15

streptococcus pneumoniae

haemophilus influenzae

Question 16

Abx treatment of otitis media?

Answer 16

implicated if TM perforation
also if more likely bacterial infection-patient has ear pain and low-grade fever but lacks cold like symptom of runny or blocked nose, sore throat, cough and headache
treat with amoxicillin PO for 5-7 days
if return with discharging ear, take a swab

Question 17

treatment of bacterial otitis externa?

Answer 17

gentamicin- as otitis externa usually caused by gram -ve organism-pseudomonas aeruginosa
DON’T prescribe if risk of TM perforation due to ototoxicity-can damage inner ear, ?if pt can blow out of ear with nose pinched-implies perforation

Question 18

commonest cause of bronchiolitis in children?

Answer 18

RSV-respiratory syncytial virus

Question 19

when should hosp r/f be made in cases of bronchiolitis in children?

Answer 19

poor feeding, inadequate to maintain hydration
hx of apnoea
RR more than 70 breaths/min
lethargy
cyanosis
nasal flaring or grunting
SpO2 94% or less
uncertainty regarding diagnosis
severe chest wall recession

Question 20

when does bronchiolitis present?

Answer 20

commonly in infants between 2 and 6 months old, generally children under 2 years of age, under 1 most common
=acute lower respiratory tract infection with small airway narrowing and obstruction due to increased mucus, cell debris and oedema

Question 21

RFs for severe disease and/or complications in bronchiolitis?

Answer 21

prematurity-less than 37 weeks
age less than 12 weeks old
chronic lung disease e.g. CF
congenital heart disease
insulin dependent DM
epilepsy
low birth weight
immunocompromised
down's syndrome

Question 22

symptoms of bronchiolitis?

Answer 22

initially URTI features e.g. mild rhinorrhoea, cough and fever
then paroxysmal cough, wheeze, breathlessness, cyanosis, vomiting, irritability and poor feeding
apnoeas in young infants

o/e widespread fine inspiratory crackles diagnostic

Question 23

management of bronchiolitis?

Answer 23

in most children, usually a mild self-limiting illness which can be treated at home
must pay attention to fluid input, temperature control and nutrition
steam inhalation may be of benefit
reassure parents crying is normal, if child was to become drowsy and quiet then would be worried and require hosp admission
can take 2-3 weeks to settle down, but for most lasts 7-10 days
bronchodilators with a spacer e.g. aerochamber and corticosteroids of limited benefit

Question 24

when would we consider taking a swab in otitis externa?

Answer 24

if failed treatment or frequent recurrence suggesting bacterial or fungal infection

Question 25

overall management of otitis externa?

Answer 25

common presentation in adults e.g. swimmers, working outside, eczema
paracetamol or ibuprofen for analgesia
if mild, consider 7 day anti-inflammatory e.g. otomize spray-dexamethasone, acetic acid and neomycin sulfate
if more severe with pain, discharge or deafness, consider topical antibiotic e.g. gentamicin
oral antibiotic e.g. ciprofloxacin only if severe infection

Question 26

red flags in acute sinusitis presentation?

Answer 26

unilateral
bleeding
diplopia/proptosis
maxillary paraesthesia-assoc. with orbital fractures
orbital swelling

Question 27

usual cause of acute sinusitis?

Answer 27

often secondary bacterial infection after viral URTI
e.g. strep pneumonia, h.influenzae or moraxella catarrhalis
can also be caused by dental infection, high altitude, allergic rhinitis and swimming

Question 28

when might patients complain they get facial pain in acute sinusitis?

Answer 28

when bending, as this increases pressure in sinuses
can get maxillary pain, tooth pain
purulent rhinorrhea

Question 29

presentation of acute sinusitis?

Answer 29

Most commonly, patients present with a non-resolving cold for more than 1 week or worsening over 4-5 days, which may have a biphasic character: the initial viral infection (rhinitis) which appears to begin settling is followed by further malaise relating to the sinusitis. There may be pain over the affected sinus (this is neither sensitive nor specific and is often described as ‘pressure by the patient).There may be pyrexia, purulent nasal discharge with or without decreased or absent smell. A poor response to nasal decongestants can be suggestive and, in the intensive care setting, this diagnosis should be considered in pyrexia of unknown origin.