L38 - Common ENT Inflammatory Diseases

Question 1

Classification of Rhinitis?

Answer 1

Classify by cause:

• Infective
• Allergic
• Others

Question 2

List the pathogens that cause infective rhinitis?

Answer 2

1) URTI Viruses

2) Bacteria – common ones in upper respiratory tract:
a) Haemophilus influenzae
b) Streptococcus pneumoniae
c) Staphylococcus aureus
d) Moraxella catarrhalis
e) Mycobacteria

3) Others: Fungi, Protozoa, Parasites

Question 3

How to distinguish allergic or infective cause of rhinitis by P/E?

Answer 3

Infective = Cloudy, white discharge from swollen inferior turbinate not to be confused with nasal polyps

Allergic = Red, swollen inferior turbinate

Question 4

Pathogenesis of chronic allergic rhinitis?

Answer 4

Type I hypersensitivity involving IgE

Allergen at nasal epithelium
> Mast cell degranulation
> release inflammatory mediators i.e. Histamine
causing sneezing, epistaxis
> Late-phase response involve cellular infiltration (i.e. eosinophils) to cause chronic nasal obstruction

Question 5

List some causative agents of rhinitis apart from infective or allergic cause.

Answer 5

Others:

• Occupational: intermittent, persistent
• Drug-induced: aspirin, others
• Hormonal (pregnancy)

Question 6

List the paranasal air sinuses? Convergence point of all sinuses?

Answer 6

Sinuses (on both sides = 8 in total):

Maxillary
Ethmoid
Frontal
Sphenoid

All converge at middle meatus

Question 7

Pathogenesis of sinusitis?

Answer 7

Functional / anatomical impairment of normal mucociliary clearance on the Respiratory epithelium

> > Swelling of osteomeatal complex

Question 8

Investigations for sinusitis and typical findings?

Answer 8

1) Endoscopy = swollen, edematous tissue + purulent discharge
2) CT = opaque sinuses and air-fluid level present

Question 9

Complications of sinusitis?

Answer 9

Orbital cellulitis
Orbital abscess
Cavernous sinus thrombosis

Question 10

Which part of the ear is most commonly infected?

Answer 10

Outer ear = common

Middle ear = less common

Inner ear = rare

Question 11

Describe the physiological protective mechanism against external ear infections?

Answer 11

Ear wax Inhibit growth of bacteria and fungi (waterproof, acidic): 
made of:
- Desquamated cells 
- Cerumen from ceruminous glands 
- Sebum 

Pars tensa epithelium migrates outwards to external ear canal&raquo_space; ear wax made at inner ear canal is constantly pushed out with no accumulation

Question 12

Pathogenesis of otitis externa?

Answer 12

Inflammatory reaction in ear canal skin (e.g. pathogens, scratching)

> > swelling, blocking rapid cell turnover

> > more dead skin produced

> > Germs breed on moist dead skin, toxic pus fills ear canal

> > Increase inflammation, viscous cycle

Question 13

Investigation and expected findings for otitis externa?

Answer 13

Direct endoscopy:
- Bacterial = red, edematous ear canal with abundant pus and dead skin

• Fungal = black spores, edematous ear canal with lots of hyphae

Question 14

2 forms of otitis media?

Answer 14

1) Acute Otitis media

2) Chronic Suppurative Otitis media = Residual perforation, can be active/ discharging or Inactive/ dry

Question 15

Symptoms, pathogen and typical endoscopic finding of acute otitis media?

Answer 15

pain, fever, hearing loss, discharge

Viral / bacterial (Streptococcus pneumoniae, Haemophilus influenzae) (asso. with URTI)

Red, congested, engorged eardrum, bulging due to pus accumulation behind

Question 16

Complications of acute otitis media? (5)

Answer 16

1) Tympanic membrane rupture with pus discharge from middle ear
2) Pus Into mastoid cavity = mastoid abscess (bulge behind ear)
3) Facial nerve palsy (affected side = drooping, no wrinkles, cannot close eyes)
4) CN VI palsy (lateral rectus) – cannot abduct eye
5) Brain abscess

Question 17

List the most common pathogens that cause tonsilitis?

Answer 17

Bacterial:

• Streptococcus pyogenes
• Staphylococci
• Pneumococci
• Haemophilus influenza
• Syphilis (Treponema pallidum)
• Corynebacterium diphtheriae)
• Mycobacterium tuberculosis

Viral: rhinovirus, adenovirus, EBV

Others: Candida

Question 18

Clinical features of tonsilitis?

Answer 18

 Fever 
 Sore throat 
 Odynophagia (painful swallowing) 
 Trismus (jaw spasm/ pain)
 Otalgia (= pain referred to ear)

Question 19

Describe the normal appearance of tonsil in children and adults?

Answer 19

Children = Large tonsils

Adults = atrophied, not very visible
* large tonsils in adults is abnormal*

Question 20

Compare the appearance of tonsilitis caused by bacteria vs viral?

Answer 20

Bacterial: red swollen tonsils, throat redness, whitish spots, swollen uvula, gray furry tongue**

Viral: red swollen tonsils, throat redness (normal uvula, no white spots, normal tongue)

Question 21

Give one complication of tonsilitis? List symptoms?

Answer 21

Quinsy/ Peritonsillar abscess

Severe sore throat 
Low grade fever 
Dysphagia 
Inflammation of peritonsillar area with medial displacement of tonsil 
Bilateral airway obstruction → stridor 
Severe trismus 

Requires drainage of abscess

Question 22

Which region of the larynx is most commonly affected by croup?

Answer 22

Subglottis

Question 23

List common causative pathogens of Sialoadenitis?

Answer 23

Salivary gland infection: 
Viral: 
- Mumps 
- Coxsackievirus 
- HIV 
-  Echovirus 

Bacterial:

• Staphylococcus
• Mycobacterium tuberculosis
• Syphilis (Treponema pallidum)

Noninfectious inflammatory: Sjogren’s (autoimmune)

Question 24

Pathogenesis of sialadenitis?

Answer 24

1) Ascending salivary duct infections: related to dehydration, debilitation
2) Secondary to salivary duct obstruction (submandibular gland more likely obstructed by stones than parotid gland)

Question 25

Give one example of parotid gland infection.

Answer 25

Parotiditis e.g. viral: mumps

Question 26

Presentation of secondary ductal obstruction of submandibular gland?

Answer 26

Blockage by stone

> > Viscous saliva, more mucus

Question 27

Lateral pharyngeal space infection is secondary to which infections?

Answer 27

Spread of infection from adjacent structures

Odontitis, pharyngitis, tonsillitis, parotitis, otitis, mastoiditis

Question 28

Submandibular space infection is secondary to which infections?

Answer 28

Dental root abscess 50-90%

Question 29

Symptoms and primary infections causing retropharyngeal space infection?

Answer 29

Fever, sore throat, dysphagia, neck stiffness

Odontitis, peritonsillar abscess, cervical vertebral osteomyelitis, perforated pharynx