Throat Flashcards
1
Q
What are the complications of tonsillitis?
A
- Otitis media
- Quinsy
- Rheumatic fever (rare)
- Glomerulonephritis (rare)
2
Q
What are the criteria for tonsillectomy?
A
All of the following:
- Sore throat due to tonsillitis
- 5+ epidsodes in one year
- Episodes are disabling and significantly impact daily life.
If not clear cut, watchful waiting for 6 months.
3
Q
Who is the main demographic of people that get tonsillectomies?
A
2/3 are performed on children
4
Q
What are some special circumstances in which a tonsillectomy can be perfomred?
A
- Recurrent febrile convulsions secondary to tonsillitis
- Obstructive sleep apnoea/stridor/dysphagia due to enlarged tonsils
- Peritonsillar abscess if unresponsive to standard treatment
5
Q
What are the primary complications of a tonsillectomy?
A
Pain
Haemorrhage in 2-3% due to inadequate haemostasis
6
Q
What are the secondary complications of a tonsillectomy?
A
Haemorrhage due to infection
Pain
7
Q
Which age groups is tonsillitis most common in?
A
Children age 5-10 and young adults aged 15-25
8
Q
What are the risk factors for tonsillitis?
A
Immune deficiency
Family hx of tonsillitis or atopy
9
Q
What are the symptoms of tonsillitis?
A
Throat pain, inc. with swallowing Pain may refer to ears Small children may complain of abdominal pain Headache Loss of/changes in voice
10
Q
What are the signs to look for on examnation of someone with ?tonsillitis?
A
- Reddened throat
- Tonsils swollen
- Tonsils may have white coating or flecks of pus
- Prexia
- Swollen regional lymph nodes
11
Q
What are the differentials for tonsillitis?
A
- Common cold
- Coxsackie virus infection
- Infectious mononucleosis
- HSV infection
- Epiglottitis
12
Q
Are throat swabs and rapid antigen tests recommended for Ix tonsillitis?
A
Nope
13
Q
What Ix are needed for tonsillitis?
A
Urgent bloods inc. FBC if immunodeficiency is suspected.
Also med review incase pt is on a drug that can cause agranulocytosis.
14
Q
What are the criteria for diagnosis of bacterial tonsillitis?
A
Centor criteria:
- Hx of fever
- Tonsilar exudate
- No cough
- Tender anterior cervical lymphadenopathy
15
Q
What is the fever pain score?
A
Fever - over 38 degrees Purulence Attended within 3 days Inflamed tonsils No cough
Predicts if tonsilitis bacterial or not.
If 4/5 scored, indicates bacterial tonsilitis. Still doesn’t mean they should have abx.
16
Q
How can we manage tonsillitis conservatively?
A
- Advise staying at home from work/avoid social contact
- Reassure that it is self limiting
- Watchful waiting is appropriate for children with mild recurrent sore throats
17
Q
How can we manage tonsillitis medically?
A
- Antipyrexials/analgesics e.g. paracetamol
- Abx often have no effect on duration or severity of symptoms, but can be considered if there is marked systemic upset, unilateral peritonsillitis, immunodeficiency etc.
- Safety net with back-up prescription if no improvement/significant worsening in 3-5 days.
18
Q
What are the abx of choice for tonsillitis if you do need to give them?
A
- Phenoxymethylpenicillin
- Clarithromyicn/erythromycin if pen allergic
Avoid amoxicillin if there is any possibility of glandular fever!!
19
Q
How long does acute tonsillitis typically last for?
A
One week.
20
Q
Are there any preventative measures that we can take to reduce incidence of tonsillitis?
A
Smoking cessation for pt or parents of pt if child.
21
Q
What is laryngopharyngeal reflux?
A
aka silent reflux, or Extra Oesophageal Reflux.
Common condition where the oesophageal spincter is incompetent to the degree that stomach acid refluxes into the oesophagus and larynx causing irritation and hoarseness.
22
Q
What are the symptoms of laryngopharyngeal reflux?
A
- Globus
- Hoarse/tight/croaky voice
- Frequent throat clearing
- Sore/dry/sensitive throat
- Occasional symptosm of GORD
- Sudden coughing/choking at night
- Chronic cough
23
Q
How should suspected silent reflux be diagnosed?
A
Throat and larynx examination by endoscope passed through the nose.
24
Q
What are the causes of silent reflux?
A
Lifestyle - overweight, smoking, high alcohol intake, high caffeine intake, diet containing spicy/fatty/citrus/chocolate based foods.
Underlying problems with oesophagus/sphincter/stomach.
25
How should silent reflux be managed?
- Lifestyle and dietary changes.
- Steam inhalation twice a day, avoid shouting/singing/whispering/talking over background noise
- Antacids/Alginates/H2 blockers/PPI
- Consider surgery if medication and lifestyle modifications not effective.
26
A pt presents to GP with excessive tiredness in the daytime. He says he wakes up repeatedly in the night, and his wife says he stops breathing just before he wakes up. What is your top differential?
Obstructive sleep apnoea syndrome
27
What is obstructive sleep apnoea syndrome?
Clinical condition in which there is intermittent and repeated upper airway collapse during sleep.
28
What is complete apnoea defined as?
Ten second pause in breathing activity.
29
What is partial apnoea defined as?
Ten second period in which ventilation is reduced by at least 50%
30
How common is obstructive sleep apnoea?
4% in middle aged men, 2% in middle aged women
31
What are the risk fators for obstructuve sleep apnoea?
```
Obesity - strongest RF.
Male gender
Middle age
Smoking
Sedative drugs
Excess alcohol
FHx
Obese children
```
32
What are the sympotms of obstructve sleep apnoea?
- Excessive day time sleepiness
- Impaired concentration
- Snoring
- Choking episodes during sleep
- Witnessed apnoeas
- Nocturia
- Decreased libido
33
What might you find on examination if someone has suspected obstructive sleep apnoea?
- Obesity
- Neck circumference high
- Certain craniofacial features assoc. with OSAS (enlarged tonsils, macroglossia, micrognathia)
- Nasal deformity
34
A pt presents to GP with excessive tiredness in the daytime. He says he wakes up repeatedly in the night, and his wife says he stops breathing just before he wakes up. What are your differentials?
- Fragmented sleep
- Sleep deprivation
- Shift work
- Depression
- Narcolepsy
- Hypothyroid
- Drugs - sedatives/stimulants/beta blockers/SSRIs/alcohol
- Neurological conditions
35
How is obstructive sleep apnoea diagnosed?
Clinically + nocturnal monitoring - 5 or more respiratory events per hour in association with symptoms of sleep disordered breathing.
36
What conditions are associated with OSAS?
```
HTN
CVS disease
Obesity
Metabolic syndrome
Diabetes
Asthma
```
37
How should OSAS managed?
Aim to restore optimal breathing and relieve symptoms:
- Lifestyle modifications - weight loss, smoking cessation, alcohol avoidance
- Pt education
- CPAP for min 4 hours each night/Bi-level PAP if intolerant.
- Pharmacological - manage allergy if contributing factor, modefinil if compliant with CPAP.
- Surgery - not great evidence, tonsillectomy/adenoidectomy in children if appropriate.
38
What are the complications of OSAS?
- Excessive daytime sleepiness - may cause accidents at home/work/in car
- Irritability/depression/psychological consequences
- Increased risk of stroke
39
What is inflammation of the salivary gland called, and what are its causes?
Sialadenitis.
| Infection and autoimmune
40
What is a peritonsillar abscess also known as?
Quinsy
41
What is the pathophysiology of peritonsillar abscess?
Inflammation of pharyngeal tonsils causing pus to become trapped between the tonsillar capsule and the lateral pharyngeal wall.
42
What organisms cause quinsy?
```
Usually mixed flora:
-Strep. pyogenes
-Staph. aureus
-H. influenzae
-Anaerobic organisms
Can also be secondary to infectious mononucleosis.
```
43
How does a pt with quinsy present?
Usually hx of tonsillitis, but not always.
Severe throat pain, may become unilateral.
Fever
Drooling of saliva
Foul smelling breath
Trismus and hot potato voice
Earache on affected side
44
What might you find on examination of a pt with suspected quinsy?
- May be difficult to open mouth
- Bad breath and drooling
- Fever
- Tender enlarged lymph nodes
- Torticollis
- Uvula displaced away from lesion, medial/anterior shift of affected tonsil
45
How is quinsy diagnosed?
Clinically
Imaging can be used to guide drainage but not usually in diagnosis.
46
How should quinsy be managed?
ABCDE
Airway compromise is rare, but should make sure the airway is patent, or call for airway support.
May need - IV fluids, analgesia, IV abx, IV Ig in rare cases. One off steroid dose may help.
Get ENT involved for further Mx.
47
What surgical Mx can be done for quinsy?
- Needle aspiration, incision, and drainage.
| - Can be USS guided if difficult to reach or prev unsuccessful
48
What are the complications of quinsy?
- Necrotising fasciiti in neck
- Mediastinitis/pericarditis/pleural effusions due to spread through anatomical planes.
- Rarely airway compromise
- Recurrence
- Haemorrhage
- Aspiration
- Death
49
Who are retropharyngeal abscesses usually seen in?
Infants or young children
50
What is the pathophysiology of acute retropharyngeal abscess?
Suppuration of retropharyngeal lymphs nodes from infected tonsil, adenoid, tooth, or penetrating foreign body
51
Which organisms commonly cause acute retropharyngeal abscesses?
- Beta haemolytic strep
- Staph aureus
- H. parainfluenzae
- Bacteroides spp.
52
What are chronic retropharyngeal abscesses usually due to, and how common are they?
Rare
| Tuberculosis of the spine
53
How common are retropharyngeal abscesses?
Uncommon due to increased use of abx in suppurative upper resp. infections.
Used to be a childhood illness, but occurs n adults now too.
54
How do retropharyngeal abscesses present?
Sore throat, dysphagia, trismus, stridor, dribbling of saliva, and a high fever. I.e it looks a lot like quinsy, but can rapidly lead to airway obstruction.
55
What would you look for on examination of a child to distinguish between retropharyngeal abscess and quinsy?
- Smooth bulge on one side of midline of posterior pharngeal wall
- Usually the pain is worse in retropharyngeal abscesses and the child won't let you examine them
56
Retropharyngeal abscesses?
https://patient.info/doctor/retropharyngeal-abscess
57
Globus sensation?
https://patient.info/doctor/globus-sensation-pro
58
Hoarseness?
passmed +
https://patient.info/doctor/hoarseness-pro
59
Define hoarseness?
| How can people describe hoarse voice?
Subjective term for weak or altered voice.
Breathy, harsh, tremulous, weak, reduced to a whisper, vocal fatigue.
60
What signs should you look out for with hoarse voice that might indicate airway compromise?
- Dyspnoea
- Stridor
- Wheeze
- Anxiety
- Signs of hypoxia
- Dysphagia or drooling
- Facial or oral oedema
61
How should hoarse voice with airway compromise be managed?
ABCDE!!!
- Don't examine the throat as may be distressing
- Get senior help/call an anaesthetist
- Treat the cause
62
What are the causes of hoarse voice?
- Smoking
- Excess alcohol consumption
- GORD
- Professional voice use (teaching/acting/singing)
- Environment (poor acoustics/atmospheric irritants/low humidity)
- Type 2 diabetes
63
What is the physiology of the voice?
- Sound is produced in the larynx by vibration of the vocal cords, and resonates in the pharynx, nose, and mouth.
- Vagus nerve innervates laryngeal muscles via superior and recurrent laryngeal nerves.
- Coughing requires adduction of vocal cords.
64
What are the broad classes of causes of hoarseness?
```
Infections
Benign laryngeal conditions
Malignancy
Neurological
Systemic
Functional dysphonia
```
65
What is functional dysphonia?
Hoarseness of voice where no organic cause is found. This is a diagnosis of exclusion.
66
Which infections can cause hoarse voice?
Acute laryngitis - v common.
| Other infections e.g. fungal, TB
67
Which benigns laryngeal conditions cause hoarse voice?
Voice overuse - v common.
| Benign vocal cord lesions e.g. nodules, polyps, papillomas
68
Which malignant laryngeal conditions cause hoarse voice?
Laryngeal cancer
| Other neck and chest tumours, esp. apical lung cancer, thyroid cancer, lymphoma.
69
Which neurological conditions cause hoarse voice?
- Laryngeal nerve palsy
- Stroke
- Parkinson's
- Motor neurone disease
- Essential tremor
- Myasthenia gravis
70
Which systemic conditions cause hoarse voice?
Endocrine - hypothyroidism, acromegaly
RA
Granulomatous disease
Autoimmune disorders
71
A pt comes into see their GP about weak, croaky voice. What do you need to ask from the history?
```
SQITARS
Check what the patient means by the words they use.
Occupation
Other ENT symptoms
Smoking and alcohol
Reflux
PMHx
```
72
A pt comes into see their GP about weak, croaky voice. What do you need to illicit from an examination?
- Signs of airway obstruction?
- Listen to voice, assess cough and swallowing
- Examine neck for scars, swelling, deformity, tenderness
- Any signs of an underlying cause
- Systemic symptoms - weight loss, tremor, fever
- Chest/neuro examination if appropriate
73
What will be assessed by ENT in a pt who has a hoarse voice?
- Indirect laryngoscopy/nasendoscopy
- Voice pathologist will often be present for MDT assessment of the pt
- GRBAS assessment to evaluate voice quality
- Reflux assessment
74
How should pts with a hoarse voice be referred from primary care?
If persisting for 3+ weeks, malignancy needs to be excluded.
2ww to appropriate speciality depending on +-lung symptoms or H&N symptoms
Arrange an urgent CXR
75
What non surgical Mx can we do for hoarse voice?
- Treat any underlying cause like reflux
- Lifestyle modification - hydration, avoid smoking/alcohol/vocal strain/caffeine
- Voice therapy, and voice clinic if no initial improvement
76
What surgical Mx can we do for hoarse voice?
- First line for laryngeal papillomas
- Persistent nodules and polyps may need surgery
- Use voice therapy as an adjunct
