Throat and nose Flashcards
Features of tonsillitis
- Sore throat
- Difficulty swallowing
- Pyrexia
- General malaise
- Halitosis
- Lymphadenopathy
- Exudative inflammation
- Enlargement of the tonsils
Cause of tonsilitis
Usually caused by beta-haemolytic Streptococcus, Pneumococcus or Haemophilus influenzae. Sometimes it occurs secondary to to an initial viral infection.
Treatment of tonsilitis (Patient can still eat and drink)
Mild
- Bed rest
- Simple analgesia
- Oral fluid replacement
Severe
- Oral antibiotics
Treatment of tonsilitis if patient unable to eat and drink
- Admit
- IV fluids
- IV antibiotics (Benzylpenicillin + Metronidazole)
- Analgesia
- Consider dexamethasone
Why should amoxicillin never be given for tonsilitis?
If the tonsilitis is caused by glandular fever the amoxicillin can result in a rash
Investigations for tonsilitis
- FBC
- Monospot
Complications of tonsilitis
- Febrile convulsions in children
- Infection may spread to form an abscess eg peritonsillar abscess (quinsy)
Clinical features of peritonsillar abscess (quinsy)
- Prodome 2-3 days of sore throat then pyrexia + marked odynophagia
- Characteristic displacement of the uvula towards the unaffected side
- Trismus
- Palpable tender juguldigastric lymph nodes
Why does trisumus occur in quinsy?
Due to inflammation of the pterygoid muscles
Treatment of quinsy
- Decompression of the abscess by aspiration or incision (leads to instant symptomatic relief)
- Antibiotics
What are the absolute indications for tonsillectomy?
- Suspected malignancy
- As part of another procedure eg uvulopalatopharyngoplasty
- Child with obstructive sleep apnoea syndrome
Relative indication for tonsillectomy
- Recurrent acute tonsillitis (3 attacks per year for 2 years, or 5 attacks in 1 year)
- Chronic tonsillitis
- Previous quinsy
- Febrile convulsions
What is Ludwig’s angina?
Infection of the submandibular space
What is the most common cause of Ludwig’s angina?
It usually results from dental infection, Streptcoccus viridans is the most commonly isolated pathogen.
Presentation of Ludwig’s angina
- Pyrexia
- Drooling
- Trismus
- May have airway obstruction due to backward displacement of the tongue
- Firm swelling of the tissues of the floor of the mouth
Treatment of Ludwig’s angina
IV antibiotics (incision seldom finds any pus).
If airway is threatened, a tracheostomy may be required.
Causes of epistaxis
Local causes:
- Idiopathic
- Trauma
- Infection
- Tumours
Systemic causes:
- Hypertension
- Anticoagulant drugs/NSAIDs
- Haematological diseases eg haemophilia, Von Willebrand’s disease
Sites of Epistaxis?
Anterior bleeds – originate from ruptured blood vessels in Little’s area (cause around 90% of cases)
Posterior bleeds – originate from the posterior nasal cavity, typically from branches of the sphenopalatine arteries of the nose, and cause around 10% of cases (more common in older patients)
Little’s area (also known as Kiesselbach’s plexus) is found on the anterior nasal septum and is an anastomosis of 5 arteries:
- anterior ethmoidal artery
- posterior ethmoidal artery
- sphenopalatine artery
- greater palatine artery
- septal branch of the superior labial artery
History to ask in epistaxis
- recent trauma
- co-morbidities
- previous episodes
- any facial pain, otalgia, systemic symptoms, or clinical features of clotting disorders
- familial conditions (especially clotting abnormalities)
- relevant drug history
Initial management of epistaxis
- Patients should be kept sat up and sat forward. Encourage patient to spit out blood in their mouth.
- Compression should be applied to the anterior nose (the nares) for 20 minutes without releasing pressure.
- Ice can be applied to the bridge of the nose to stimulate further vasoconstriction.
If conservative management of epistaxis is unsuccessful:
- If bleeding point identified, the vessel can be cauterised using silver nitrate
- If there is too much blood present to visualise the septum, adrenaline soaked gauze can be inserted into the nasal cavity to cause localised vasoconstriction and soak up any excess blood
- If epistaxis persists but no bleeding point is identified, anterior packing should be trialled
Bloods that should be tested for epistaxis:
- FBC
- Clotting
- Group and save
How would you manage a fractured nose?
- Exclude septal haematoma
- Boggy swelling in both nostrils
- Requires incision and drainage
- Reassess for deviation after 7 days once nasal swelling has subsided
- Only need to intervene if cosmetic deformity or nasal obstruction
Symptoms of sinusitis
Common to both acute and chronic sinusitis:
- Facial pain
- Headache
- Nasal obstruction
- Anosmia
- Halitosis
Acute sinusitis:
- Systemic upset, pyrexia ect
- Rhinorrhoea with pus
Chronic sinusitis
- Otherwise well
- Postnasal drip
- Muzzy head
- Poor concentration
What is acute sinusitis ?
Inflammation of the mucosal linings of the nasal passage and paranasal sinuses.
Risk factors for acute rhinosinusitis:
- Cigarette smoke exposure (active or passive)
- Air pollution exposure
- Anatomical variations (such as septal deviation, nasal polyps, or sinus hypoplasia)
The diagnosis of acute rhinosinusitis requires the sudden onset of two or more of the following symptoms:
- Nasal obstruction
- Discoloured nasal discharge
- Facial pain or pressure
- Altered sense of smell
Differential diagnosis for acute rhinosinusitis:
- Viral upper respiratory tract infection
- Allergic rhinitis
- Facial pain syndromes (eg migraines, cluster headaches, mid-segmental facial pain)
Investigations for acute sinusitis
- Diagnosis typically made on clinical symptoms alone
- CT scan is complications suspected
- Skin prick testing in patients with recurrent episodes and symptoms suggesting allergic rhinitis
Initial management of acute sinusitis
1) For patients with symptoms up to 5 days (or >5 days but improving
2) For cases more than 10 days or worsening after 5 days
- Analgesia and nasal decongestants
- Topical nasal steroids and oral antibiotics
How would you differentiate between acute and chronic sinusitis?
The symptoms of acute sinusitis last for less than 12 weeks while the symtoms of chronic sinusitis last longer that 12 weeks.
Risk factors for chronic sinusitis
- Asthma or atopy
- Aspirin sensitivity
- Ciliary impairment (eg cystic fibrosis or primary ciliary dyskinesia)
- Smoking
- Immunosuppression
All cases of chronic rhinosinusitis should undergo which procedure?
Rhinoscopy
Differential diagnosis for chronic sinusitis
- Recurrent acute rhinosinusitis (consider if there is resolution of symptoms between episodes
- Malignancy (consider in cases of unilateral nasal polyposis, the presence of bloodstained discharge, or eye signs)
- Foreign bodies (more common in children and typically present with nasal obstruction and discoloured unilateral discharge)
To make a formal diagnosis of chronic sinusitis, nasal endoscopy is required. At least one of the following signs should be present:
- Mucosal swelling
- Mucopurulent discharge
- Mucosal occlusion of middle meatus
- Nasal polyps
Management of chronic sinusitis
- Mild disease - treated with nasal saline douching and topical steroid spray or drops
- Moderate to severe disease - long term antibiotics with topical steroids and CT imaging of the sinuses
- Refractory cases -functional endoscopic sinus surgery
What is the aim of functional sinus surgery?
To remove any polyps that have formed and open up the sinuses. This will reduce obstruction, drain any collections of mucus and allow topical treatments to reach all areas to prevent recurrence.
