Respiratory/ ENT Flashcards
1
Q
What are the key signs of choking in a child?
A
- Inability to talk
- Inability to breathe or noisy breathing
- Weak or ineffective cough
- Cyanosis
- Potential loss of consciousness
2
Q
What is the most common cause of choking in a child?
A
Aspiration of food or small objects
3
Q
What is the management of choking in a child?
A
If conscious and can cough:
- Encourage the child to cough to dislodge the obstruction
If conscious but unable to cough effectively:
- Alternate between giving 5 back blows and 5 chest (infant)/ abdominal (child) thrusts
If unconscious:
- 5 rescue breaths, then immediately commence CPR
4
Q
What is the first step in asthma management of a child 0-5 years old?
A
SABA (for relief of symptoms)
Salbutamol inhaled: 100micrograms/dose metered-dose inhaler)
1-2 puffs every 4-6 hours when required
5
Q
What indicates that an asthmatic child 0-5 years old on step 1 of managment needs treatment escalation?
A
Use of SABA inhaler on average more than twice a week over 1 month
OR
Newly-diagnosed asthma with symptoms >=3/ week or night-time waking
6
Q
What is the second step in asthma management of a child 0-5 years old?
A
SABA+8 week trial of paediatric moderate-dose inhaled corticosteroid
Beclometasone, budesonide, ciclesonide, fluticasone, mometasone
7
Q
What should be done after 8 weeks in an asthmatic child 0-5 years old on step 2 of treatment?
A
Stop the ICS and monitor the symptoms:
- If they haven’t resolved consider another diagnosis
- If symptoms have stopped and then reoccur within 4 weeks, restart the ICS at a low dose as first-line maintenance therapy
- If symptoms resolve but reoccur beyond 4 weeks, repeat the 8 week trial
8
Q
What is the third step in asthma management of a child 0-5 years old?
A
SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)
9
Q
What is the fourth step in asthma management of a child 0-5 years old?
A
Stop the LTRA and refer to a paediatric asthma specialist
10
Q
What is the first line asthma management for children 5-16?
A
SABA
11
Q
What is the second line asthma management for children 5-16?
A
SABA+paediatric low-dose inhaled corticosteroid
12
Q
What is the third line asthma management for children 5-16?
A
SABA+paediatric low-dose ICS+leukotriene receptor antagonist (LRTA)
13
Q
What is the fourth line asthma management for children 5-16?
A
SABA+paediatric low dose ICS+LABA
Stop a LTRA at this point if it’s not helping
14
Q
What is the fifth line asthma management for children 5-16?
A
SABA+switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a paediatric low-dose ICS
15
Q
What is the sixth line asthma management for children 5-16?
A
SABA+paediatric moderate-dose ICS MART
OR
Consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA
16
Q
What is the seventh line asthma management for children 5-16?
A
SABA+one of the following options:
- Increase ICS to paediatric high-dose, either as part of a fixed-dose regime or as a MART
- A trial of an additional drug (eg. theophylline)
- Seeking advice from a healthcare professional with expertise in asthma
17
Q
What is the asthma maintenance and reliver therapy (MART)?
A
- A form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms required
- MART is only available for ICS and LABAL combinations in which the LABA has a fast-acting component (eg. formoterol)
18
Q
What does NICE recommend in terms of patients who have well controlled asthma, but the guidelines have changed?
A
It does not advocate for changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance
19
Q
What constitutes the low, moderate and high doses of ICS?
A
- Low dose: <= 200 micrograms budesonide
- Moderate dose: 200-400 micrograms budesonide
- High dose: >400 micrograms budesonide
20
Q
Why does NO correlate with levels of inflammation?
A
NO is produced by three types of nitric oxide synthases - one of the types is iNOS (inducible) and levels tend to rise in inflammatory cells, particularly eosinophils
21
Q
What is the age threshold for objective testing for asthma?
A
Children >=5 years old
22
Q
What are the diagnostic tests for asthma in children 5-16 years old?
A
- Spirometry with a bronchodilatory reversibility test
- FeNO should be requested if there’s normal spirometry or obstructive spirometry with a negative bronchodilatory reversibility
23
Q
What FeNO threshold is considered a positive result in children?
A
> = 35ppb
24
Q
What is the spirometry vale that indicates asthma?
A
FEV1/FVC ratio less than 70% is considered obstructive
25
What indicates a positive bronchodilator reversibility test in children?
Improvement in FEV1 or 12% or more
26
What constitutes a life-threatening asthma attack in children >5?
- SpO2 <92%
- PEF <33% best or predicted
- Silent chest
- Poor respiratory effort (CO2 levels normal on blood gas - exhaustion meaning CO2 can't be blown off)
- Agitation
- Altered consciousness
- Cyanosis
27
What constitutes a severe asthma attack in children >5?
- SpO2 <92%
- PEF 33-50% best or predicted
- Too breathless to talk or feed
- Heart rate (>125 >5 years, >140 1-5)
- Respiratory rate (>30 breaths/ min >5, >40 breaths/ min 1-5)
- Use of accessory neck muscles
28
What constitutes a moderate asthma attack in children >5?
- SpO2 >92%
- PEF >50% best or predicted
- No clinical features of severe asthma
29
What is the management of a mild-moderate acute asthma attack?
Bronchodilator therapy
- Beta-2 agonist via spacer (children <3 use close-fitting mask)
- 1 puff every 30-60 seconds up to a max of 10 puffs
- If symptoms are not controlled, repeat beta-2 agonist and refer to hospital
Steroid therapy
- All children with asthma exacerbation
- Treatment for 3-5 days
- Oral prednisolone
30
What are the doses of oral prednisolone given during asthma attacks?
2-5 years
- 20mg od (1-2mg/kg od, max 40mg)
>5 years
- 30-40mg of (1-2mg/kg od, max 40mg)
31
What is the A-E management of acute severe asthma?
- Continuous O2 sats monitoring
- High flow O2 via non-rebreathe mask to achieve sats 94-98%
- Nebulised salbutamol (2.5-5mg) every 20 mins with ipratropium bromide (250mcg) for first 2 hours
- Oral prednisolone
- Consider IV Mg and amiophylline if the child is still unresponsive after the maximum doses of bronchodilators and steroids
- Consider ABG if poor response to early treatment
- Refer to PICU
32
What is the mechanism of ipratropium bromide?
Acetylcholine antagonise via blockade of muscarinic cholinergic receptors
33
What is the A-E management of life-threatening acute asthma?
- Continous O2 sats monitoring
- High-flow O2 via non-rebreathe mask titrated to achieve sats of 94-98%
- Refer to PICU
- Salbutamol (2.5-5mg) every 20 mins with ipratropium bromide (250mcg) for first 2 hours
- Oral prednisolone
- Repeat dose of oral pred if vomiting, or consider IV steroids (hydrocortisone 4mg/kg every 4 hours)
- Give bolus of IV Mg
- Consider bolus of IV salbutamol if child has responded poorly to all other treatments, followed by infusion
- Consider aminophylline if still unresponsive to maximal doses
- Consider ABG if poor response to early treatment
34
What is the most common causitive pathogen of bronchiolitis?
Respiratory syncytial virus (RSV) - 70-80% of cases
35
When is the incidence of bronchiolitis higher?
Winter
36
Which patient group are most affected by bronchiolitis?
Most common serious lower respiratory tract infection in <1 year olds, peak incidence 3-6 months
- Maternal IgG provides protection to newborns against RSV
37
What are the non-RSV causes of bronchiolitis?
- Mycoplasma
- Adenoviruses
- Influenza
- Rhinovirus
- Parainfluenza virus
- Human metapneumovirus
- Can be secondary to a bacterial infection
38
What are the clinical features of bronchiolitis?
Coryzal symptoms (including mild fever) proceeding:
- Dry cough
- Increasing breathlessness
- Wheezing, fine inspiratory crackles
- Feeding difficulties associated with increasing dyspnoea
- Nasal flaring
- Grunting
39
When should a child immediately be referred (usually be ambulance) to hospital in suspected bronchiolitis?
- Apnoea
- Child looks seriously unwell
- Severe respiratory distress eg. grunting, marked chest recession, resp rate >70 breaths/ min
- Central cyanosis
- Persistent O2 sats <92% when breathing air
40
When should clinicians consider referring a suspected case of bronchiolitis to hospital?
- Resp rate >60 breaths/ minute
- Difficulty with breastfeeding or inadequate oral fluid intake (50-70% of usual volume)
- Clinical dehydration
41
What investigations can be done for bronchiolitis?
It should be diagnosed clinically, but if there is doubt:
- Immunofluorescence of nasopharyngeal secretions may show RSV
- Chest x-ray may be considered in severe cases or if there's concern about complications
42
What is the management of bronchiolitis?
- Humidified O2 given via a head box, recommended in O2 sats are persistently <92%
- NG feeding if children can't take enough fluid/ feed by mouth
- Suction sometimes used for excessive upper airway secretions
- Ribavirin (antiviral) may be used in severe cases
43
What is given prophylactically to prevent bronchiolitis in high risk patients?
Palivizumab
44
What is the complication of bronchiolitis?
Bronchiolitis obliterans
- Bronchioles are injured due to infection leading to overactive cellular repair and build up of scar tissue
- Scar tissue obstructs the bronchioles, impairing O2 absorption
- Scarring can worsen over time leading to resp failure
45
Which patient group is at highest risk of developing bronchiolitis obliterans as a complication of bronchiolitis?
Lung transplant recipients, ~50% develop condition within 5 years of transplant due to organ rejection
46
What is croup?
An upper respiratory tract infection seen in infants and toddlers. Characterised by stridor
47
What causes stridor in croup?
- Laryngeal oedema (mainly this)
- Tracheal oedema
- Bronchial oedema
- Secretions
48
What is the most common cause of croup?
Parainfluenza virus
49
What is the peak incidence of croup?
6 months - 3 years
50
What are the general features of croup?
- Stridor
- Barking cough (worse at night)
- Fever
- Coryzal symptoms
51
What are the features of mild croup?
- Occasional barking cough
- No audiable stridor at rest
- No or mild suprasternal and/ or intercostal recession
- The child is happy and prepared to eat, drink and play
52
What are the features of moderate croup?
- Frequent barking cough
- Easily audiable stridor at rest
- Suprasternal and sternal wall retraction at rest
- No or little distress or agitation
- The child can be placated and is interested in its surroundings
53
What are the features of severe croup?
- Frequent barking cough
- Prominent inspiratory (and occasionally expiratory) stridor at rest
- Marked sternal wall retractions
- Significant distress and agitation, or lethargy or restlessness (hypoxaemia)
- Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
54
What are the features of croup that prompt admission?
- Moderate or severe croup
- <6 months
- Known upper airway abnormalities
- Uncertainty about diagnosis
55
What are the investigations for croup?
- Majority are diagnosed clinically
- Chest x-ray can be indicated
56
What would a chest x-ray of croup show?
Subglottic narrowing, the steeple sign
57
What is the of mild or moderate croup?
Oral dexamethosone, 0.15mg/kg
2nd line
Oral prednisolone, 1mg/kg with a repeat dose the following evening
Discharge once stridor free at rest
58
What is the management of severe croup?
Nebulised adrenaline, high flow oxygen and dexamethosone (0.6ml/kg)
59
What viruses, other than the parainfluenza virus, can cause croup?
- Adenovirus
- Influenza
- RSV
60
What is the appearance of a normal tympanic membrane?
Left tympanic membrane (malleolus process is pointing left)
- Cone of light indicates a healthy ear
61
What are the features of ear wax?
- Antiseptic
- Pathogen collector
- Moisturizing
62
What is otitis externa?
Infection of the skin of the external auditory canal
Commonest in hot, humid countries
63
What are the symptoms of otitis externa?
- Irritable child
- Worsening otalgia
- Otorrhoea
- Itchiness
- Ear fullness/ tugging of the ear/ hearing loss
- Tinnitus
64
What are the risk factors for otitis externa?
- Young children
- Females > males
- Frequent contact with water
- Obstruction of the ear canal
- Ear trauma
- Foreign body in the ear
- Skin conditions: eczema, psoriasis
- Immunocompromised patients
65
What is the presentation of bacterial otitis externa on otoscopy?
66
What is the presentation of fungal otitis externa on otoscopy?
67
What is the management of bacterial otitis externa?
Localised:
- Analgesia and heat application
- Oral abx rarely required
Acute lasting <3 months:
- Keep ears clean and dry
- Consider over the counter acetic acid 2% ear drops (over 12 yrs, morning and evening, after showering etc max 7 days)
- Ibuprofen/ paracetamol
- Consider antibacterial + topical corticosteroid ear drops
Chronic lasting >3 months:
- Avoid triggers
- Analgesia PRN
- Arrange ear swab
68
What is the management of fungal otitis externa?
6 weeks of treatment even if the tympanic membrane appears normal, due to possibility of remaining spores that aren't visible to the naked eye
69
Which pathogens cause otitis externa?
Pathogens of the upper respiratory tract:
- Pseudomonas aeruginosa (~40%)
- S. Epidermis
- S. Aureusa
- Anaerobes
- Fungal infections (typically Aspergillus spp.)
70
What is acute otitis media?
Acute inflammation of the middle ear cavity
30% of children <3 are seen in the GP with AOM
Peak incidence 6-15 months
71
What are the risk factors for acute otitis media?
- Young children going to nursery
- Male
- Passive smoking (reduced immune response)
- Bottle feeding (reduced immune response)
- Craniofacial abnormalities: cleft palate, Down's syndrome
- Large adenoids
72
What are the commonist organisms causing acute otitis media?
- RSV and rhinovirus
- Streptococcus pneumoniae (40%)
- Haemophilus influenzae (25%)
73
Why are younger children more prone to otitis media?
Infants have thinner and flatter eustachian tubes therefore easier for infections from the nose and posterior nasopharynx to enter the inner ear
74
What is suspected if a child with acute otitis media becomes happy again, unilateral hearing loss persists and there is discharge leaking from the ear?
Perforation of the tympanic membrane
75
What is mastoiditis?
A severe complication of acute otitis media (ENT emergency)
The child becomes more unwell, protruding ear with red, hot, tender mass over the mastoid
Infection can spread to the brain causing meningitis and cerebral abscess
76
What is the presentation of mastoiditis on otoscopy?
Bulging and opaque tympanic membrane (red, pink or yellow) with evidence of effusion posteriorly
77
What is the management of mastoiditis?
78
What is the management of acute otitis media?
- 80% self limiting and resolves within 3 days
- >4 days and systemically well - consider oral abx
79
When would admission with acute otitis media be considered?
- Younger than 2
- Systemically unwell
- Immunocompromised
80
What is the management for recurring acute otitis media?
>6 episodes per year
- Consider grommet insertion
- Consider adenoidectomy
81
What is this?
Otitis media with effusion
82
What are the causes of tympanic membrane perforation?
- Loud sounds
- Head trauma
- Infection
- Foreign bodies in the ear
- Iatrogenic
- Cholesteatoma
83
What is this?
Traumatic perforation
84
What is this?
Perforation secondary to cholesteatoma
Migration of middle ear mucosa to the outer ear causing gradual erosion
Recurrent ear discharge that doesn't improve with antibiotics
85
What is the management of small perforations?
Watch and wait, usually heals within 6 weeks
Treat any infection
86
What is the management of cholesteatoma?
Urgent referral to ENT
87
What is otitis media effusion with glue ear?
The presence of fluid in the middle ear for >=3 months
Chronic Eustachian tube dysfunction leading to difficulty in ventilating the middle ear
88
What is the epidemiology of glue ear?
- 80% of children experience 1 or more episodes before age of 10
- Peak incidence 2-5 years
- More common in winter months
89
What can glue ear cause if left untreated?
- Irreversible hearing loss
- Delay in speech development
- Poor performance in school
90
What are the risk factors for otitis media with effusion?
- Male
- Children under 7
- Bottle fed (reduced immunity)
- Recurrent nose infections
- Passive smoking
- Craniofacial abnormalities (cleft palate, Down's syndrome etc)
- Mucociliary abnormalities (cystic fibrosis)
91
What is the presentation of otitis media with effusion?
- Majority asymptomatic (incidental finding)
- Unilateral conductive hearing loss
- Poor behaviour, attention deficit
- Delay in speech development
- Mild otalgia
- Poor coordination
92
What is the presentation of otitis media with effusion on otoscopy?
May be normal, or may look dull/ opaque with evidence of fluid level or bubbles posteriorly
93
What is a tympanogram?
A way of measuring how mobile the tympanic membrane is
94
What is the management of otitis media with effusion?
Active monitoring:
- 90% of cases resolve within 3 months
Non-surgical managment:
- Treating rhinitis
- Otovent balloon
- Hearing aids for persistent hearing loss
Surgical management:
- Myringotomy and ventilation tube insertion (grommet)
- Adenoidectomy
95
How is Weber's test conducted?
512Hz tuning fork
- Create a vibration and place in the centre of the head
- Healthy patients should hear ringing equally bilaterally
- Conductive hearing loss will be louder on the affected side
- Sensorinerual hearing loss will be louder on the unaffected side
96
How is Rinne's test conducted?
512Hz tuning fork
- Create a vibration and place beside the ear
- Then place the tuning fork on the mastoid process
- Sounds being heard louder via air conduction are healthy
- Sounds heard louder via bone conduction are pathological
97
What are audiographs?
Charts used to record an individual's hearing in different frequencies and volumes
Audiologist plays and sound and patient clicks a button everytime they hear a sound (repeated on each side)
98
What is the classification of mastoiditis?
- Acute: secondary to acute otitis media (days/ hours)
- Chronic: secondary to chronic suppurative otitis media or cholesteatoma (days/ weeks) (recurrent otitis media, recurrent headaches, recurrent otalgia, may show no peri-mastoid inflammation)
99
What are the complications of mastoiditis?
- Meningitis
- Facial nerve paralysis
- Extradural abscess
- Brain abscess
- Subdural abscess
100
What is the management of mastoiditis?
Investigations:
- FBC, Us&Es, CRP, Blood cultures
- Ear swab
IV abx
Topical abx ear drops
Contrast enhanced CT petrous bone +- brain
101
What is the management of mastoiditis if there is no response within 24 hours?
- Imaging of the brain
- Myringotomy + grommet insertion
- +- cortical mastoidectomy
102
What are the symptoms of cholesteatoma?
- Persistent oderous discharge, not improving with abx
- Progressive/ severe hearing loss
- Dizziness
- Acute mastoiditis
- Facial palsy
103
When should foreign bodies in the ear be removed?
104
What is a pinna haematoma?
Boggish, bluish swelling of the pinna
Caused by:
- Blunt ear injury eg. rugby, boxing etc
- Infection of the pinna usually secondary to a piercing
105
What is the management of pinna haematoma?
- Urgent drainage under general anaesthetic
- Apply pressure dressing
- Abx
106
What is a cauliflower ear?
Chronic inflammation due to blood between the skin and the cartilage leading to chronic misshape of the ear secondary to this (pinna haematoma preceeds)
107
What hearing test is offered to all neonates?
Automated otoacoustic emission testing
108
What is automated otoacoustic emission testing?
- Gentle clicking sound played through an earpiece
- Echo reflected back into the canal and measured by a microphone
109
What should be offered if there is a reduced echo on automated otoacoustic emission testing?
Auditory brainstem response testing
110
What is auditory brainstem response testing?
- Sounds played using earphones
- Electrodes placed on the baby's head
- Electrodes detect responses from auditory vestibulocochlear nerve
111
What is the age limit for auditory brainstem response testing?
Up to 6 months
112
What could a reduced echo on automated otoacoustic emission testing mean?
- Baby unsettled
- Background noise
- Temporary blockage in the ear
- Genuine hearing loss
113
Which patient group is epistaxis less common in?
Children <2, therefore raises suspicion of trauma or serious illness
114
Which area is most vulnerable to epistaxsis?
Kiesselbach's plexus/ Little's area (site of anastamosis for the anterior and posterior ethmoid arteries)
115
What is the management of epistaxsis?
1. A-E approach (tilt the child's head forward and hold in position shown for 15 minutes, stars indicate areas where ice can be placed to stimulate vasoconstriction)
2. Use of topical medication to cause vasoconstriction (lidocaine/ adrenaline)
3. Identify bleeding point and cauterize with silver nitrate stick
These are all interventions for bleeding in the anterior section of Kiesselbach's plexus/ Little's area, posterior bleeding requires different interventions
116
How can posterior epistaxsis be managed?
Using a foley catheter and chord clamp - catheter is inflated via water/ air to compress the bleeding site
Other methods of creating pressure:
- Merocel
- Rapid rhino
117
What is naseptin cream?
Contains an antibiotic and disinfectant and is used pre and post cauterization to promote wound healing
118
What is the mechanism of adenoidal hypertrophy?
Adenoids that have not regressed in size past the age of 7 are exposed to air on inhalation, collect bacteria and create a biofilm causing recurrent infection
Recurrent infection/ inflammation leads to adenoidal hypertrophy
119
What is the presentation of adenoidal hypertrophy?
- Persistent mouth breathing
- Hyponasal speech
- OSA
- Otitis media with effusion
- Acute otitis media
120
What are the indications for an adenoidectomy?
- Airway obstruction leading to OSA
- Otitis media with effusion
121
What is the most important post-operative care for an adenoidectomy?
- Very tender area for surgery, therefore frequent analgesia
- Encourage the child to eat and drink as soon as possible to reduce the inflammation
122
What is allergic rhinitis?
Type 1 hypersensitivity reaction causing inflammation of the nose (secondary to certain allergens)
Usually caused when a child isn't exposed to certain allergns from a young age (exposure = protective)
Aka. hayfever
123
How does allergic rhinitis present?
All related to excess fluid in facial tissues:
- Red, itchy, swollen eyes
- Nasal congestion
- Frequent bouts of sneezing
Symptoms persisting for weeks:
- Poor concentration
- Reduced sleep
- Poor attendance at work/ school
124
What is allergic rhinitis associated with?
- Asthma
- Family history of atopy
- First born child
125
How is allergic rhinitis diagnosed?
- Skin prick test
- Patch test
126
What is the managment of allergic rhinitis?
1. Avoid the allergen
2. Antihistamines (cetirizine) - can cause drowsiness
3. Nasal toileting (constant flushing of water up and down the nose)
4. In severe cases encourage desensitization (slow exposure to reduce histamine release)
127
What is rhinosinusitis?
Acute inflammation of the nose and paranasal sinuses from viral infection - this leads to inadequate drainage
Only 2% are bacterial (strep)
128
What are the most common viral causes of rhinosinusitis?
- Rhinovirus
- Coronavirus
129
What are the risk factors for rhinosinusitis?
- Air pollution
- Damp housing
- Winter months
- Exposure to tobacco smoke and other allergens
130
How does rhinosinusitis present?
- Headache
- Nasal obstruction leading to hyposmia
- Rhinorrhoea
- Facial pain
- Fever
131
What is the management of rhinosinusitis?
- Most resolve spontaneously <7 days
- Abx (only if there is fever or for symptoms lasting >7 days)
- Nasal steroids
If all fails, admit for IV abx and CT sinuses +- functional endoscopic sinus surgery
132
What is perioribital cellulitis?
Infection from the nasal sinuses, the eyes or the skin of the face that extends to surround the eye
ENT emergency - can cause perminent damage to the eye in terms of loss of vision and reduced mobility
133
How is periorbital cellulitis classed?
- Pre-septal: infection from the conjunctiva or eye lids
- Post-septal: infection from the frontal or ethmoid sinuses
134
How does perioribital cellulitis present?
- Prodrome of URTI
- Acute swelling of the eye
- Proptosis
- Restricted eye movement
135
What is the management of periorbital cellulitis?
- Nasal decongestants
- IV abx
- +- surgical drainage
136
What are the complications of periorbital cellulitis?
- Cavernous sinus thrombosis (neurological signs, visual loss, muscle paresis and papilloedema)
- Erosion of orbital bones, causing blindness
- Brain abscess
- Meningitis
137
What are the symptoms of a foreign body inside the nostril?
- Unilateral nasal discharge
- Offensive smelling discharge
- Excoriation around the nostril with foreign body
138
Why should a nasal foreign body be removed on the same day?
Due to the risk of the child inhaling it into the lung - can cause lung abscesses
If unable to remove in an ED setting, must be removed under general anaesthetic
139
What is the 'magic kiss' method for nasal foreign body removal?
- Close the nostril with the foreign body
- Ask the mother/ parent to blow air into the child's mouth
140
How should nasal foreign bodies stuck behind the inferior tubinate be removed?
- Jobdon Horn
- St Bart's Wax Hook
- Foley catheter
141
What are the complications from acute tonsillitis?
Rheumatic fever and glomerulonephitis from group B strep
142
What are the causes of pharyngitis?
- Viral disease
- EBV
- Scarlet fever
- Typhoid fever
- Coxackie infection
- Diptheria (gray film)
143
What are the complications of pharyngitis?
- Peritonsillar abscess
- Uvulitis
144
What is the management of pharyngitis?
1. 90% resolve spontaneously within 7 days
2. Analgesia, pain should start to reduce after 16 hours:
- Ibuprofen
- Paracetamol
- Difflam mouth wash
145
Which scores should be used in pharyngitis before prescribing antibiotics?
FeverPAIN or Centor Criteria scores
**Prescribe antibiotics:**
- FeverPAIN 4 or 5
- Centor 3 or 4
146
Why should all post-tonsillectomy bleeds be admited?
**ENT Emergency**
Majority are self limiting, however can cause airway obstruction and hypovolemic shock
147
How are peritonsillar bleeds divided?
**Primary:**
- Occurs within 24 hours and is usually due to lack of haemostasis during the proceedure
**Secondary:**
- Occurs within 10 days or more of the tonsillectomy, due to onset of infection
148
What is the management of post-tonsillectomy bleed?
A-E approach
1. Airway - lean the head forward
2. Breathing - if tollerated and indicated give O2 via nasal cannula
3. Circulation - IV access, bloods, IV tranexamic acid
4. Stop the bleeding using silver nitrate sticks
5. Hydrogen peroxide gargles
6. Keep NBM
7. If not bleeding for >24hrs can head home
149
What are the symptoms of foreign body aspiration?
- Short sudden episode of respiratory distress, cyanosis, coughing or gagging
- The the child appears well
- Stridor
- Unilateral wheezing
- Persistent recurrent cough
150
What is the management of foreign body aspiration?
Object needs to be removed the same day
151
What are the complications of foreign body aspiration?
- Airway obstruction (especially if in the upper airway)
- Lung abscess
- Fistula formation
152
What is the difference between stridor and stertor?
Both occur on inspiration
**Stridor:** Caused by obstructed air flow through narrow airway, indicates blockage in upper airway
**Stertor:** Caused by upper respiratory obstruction, sounds like nasal obstruction heard in snoring
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How does wheeze differ from stridor and stertor?
Wheezes are expiratory, commonly heard in Croup and Bronchiolitis
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What is the main investigation for foreign body ingestion?
AP and lateral chest x-ray
Lateral x-ray helps to determine whether the object is in the oesophagus or trachea
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What is epiglottitis?
Localised infection of the supraglottic larynx causing swelling of the epiglottis
A. Lateral x-ray
B. Severe epiglottitis
C. Moderate epiglottitis
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Which organism causes acute epiglottitis?
Haemophilus influenza type B
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What are the risk factors for epiglottitis?
- Unvaccinated children
- Children 2-6 years old
- Foreign body inhalation
- Chemical or allergens
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What is the management of epiglottitis in primary care?
- **Do not examine the child**, anything that could make the child cry/ cause irritation risks losing the airway
- Urgent admission to a hospital with PICU
- Pre-alert for difficult paediatric airway, these children need intubation and IV steroids
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What is the presentation of acute epiglottitis?
- Tripod position
- Muffled voice
- Duck cough
- Mouth open and drooling
- Stridor
- Child is quiet, unwell and terrified
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What is laryngomalacia?
When the child's larynx is soft, floppy or malformed
Common cause of stridor
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What is the management of laryngomalacia?
- 90% of cases self resolve by 20 months
- Cause of GORD, therefore manage the GORD
- Surgery (to allow for normal development and growth)
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What is the presentation of laryngomalacia?
- Stridor - worse when supine or crying
- Difficulty breathing
- Poor oral intake/ choking while eating
- Failure to thrive
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What presentation of laryngomalacia would indicate an urgent referral to ENT?
- Life-threatening apneas
- Significant blue spells
- Failure to thrive
- Significant chest and neck retractions (increased use of accessory muscles)
- Secondary heart and lung disease
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What is cervical lymphadenitis?
Enlargement of cervical lymph nodes secondary to an inflammatory condition
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What are the causes of cervical lymphadenitis?
- URT viral infection
- Bacterial infection (TB)
- Cancer
- Immunological response
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What is the presenation of cervical lymphadenitis?
- Tired child, off their food, not sleeping well
- Enlarging neck lump
- Tender
- Hot
- Erythematous
- Fluctuant (abscess formed)
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What is the management of cervical lymphadenitis?
- Antibiotics (PO-->IV)
- USS neck (doesn't expose the child to significant radiation)
- Surgery for drainage of collection (if abscess formed)
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What is the management of chronic (>3 months) otitis externa with a fungal cause?
- Clotrimazole
- Acetic acid
- Clioquinol and corticosteroid
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What is the management of chronic otitis externa with no evident cause?
7-day topical preparation containing only corticosteroid and no antibiotic, consider co-prescribing acetic acid spray
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When is urgent admission for ear infection indicated?
If malignant otitis is suspected (systemic abx and debridement)
