Throat (ENT) Flashcards
Outline the nerve supply of the tongue
Anterior 2/3:
- Facial nerve (taste)
- Mandibular branch trigeminal nerve (sensation)
Posterior 1/3:
- Glossopharyngeal (both)
State some functions of the larynx
- Ventilation (allow air passage)
- Speaking / sound production
- Cough
- Airway protection (epiglottis)
Outline the 3 main cartilage structures in the larynx
- Epiglottis
- Arytenoid cartilages
- Cricoid cartilage
State the cell type that lines the larynx and cell type that lines the true vocal cords
Larynx:
- Pseudostratified ciliated columnar epithelium
True vocal cords:
- Stratified squamous (lots of air abrasion)
Outline the route of the L&R recurrent laryngeal nerves
Left recurrent laryngeal nerve goes under the arch of the aorta (goes down further)
Right recurrent laryngeal nerve goes under the right subclavian artery
List 6 laryngeal conditions
- Laryngitis
- Laryngeal nodules
- Laryngeal cancer
- Epiglottitis
- Croup
- Laryngeal oedema e.g. anaphylaxis
Tonsillitis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Inflammation of tonsils
- Most commonly viral cause (most common bacterial cause is group A strep)
Presentation:
- Fever
- Sore throat
- Painful swallow
- Poor oral intake
- Headache
- Inflamed and enlarged tonsils +/- exudate
- May have cervical lymphadenopathy
Can present with non-specific symptoms, particularly in younger children
Investigations:
- ENT examination (throat and ears)
- Use centor / feverPAIN criteria
*Throat swabs / antigen tests not routinely performed
*Blood tests reserved for immunodeficiency patients
Management:
If viral suspected…may take up to 1 week to resolve
- Analgesia
- Safety netting advice (return if the pain has not settled after 3 days or the fever rises above 38.3ºC) = start antibiotics, or consider alternative diagnosis
- Consider delayed prescriptions
If bacterial suspected…
- Penicillin V for 10 days (Clarithromycin if penicillin allergy)
What specific antibiotic should be avoided in tonsillitis and why
Avoid Amoxicillin
Causes a maculopapular rash in EBV cause of tonsillitis
State the most common age groups affected by tonsillitis
Children aged 5-10
Another peak between ages 15 and 20
Outline the centor criteria for tonsillitis
Centor Criteria:
- Used to estimate the probability that tonsillitis is due to a bacteria infection (therefore likelihood of benefit from antibiotics)
Centor:
- Cervical lymphadenopathy
- Exudates (tonsillar)
- No cough
- Temp over 38ºC
Score of 3 or 4…
- 40-60 % probability of bacterial tonsillitis
= Appropriate to offer antibiotics
Outline the fever-PAIN criteria for tonsillitis
Fever-PAIN Criteria:
- Used to estimate the probability that tonsillitis is due to a bacteria infection (therefore likelihood of benefit from antibiotics) = alternative to centor criteria
Criteria:
- Exudates (tonsillar)
- Temp over 38ºC
- Attends within 3 days
- Inflamed tonsils
- No cough
Score of 0-1:
- Safety net and no antibiotics
Score 2-3:
- Consider delayed antibiotic prescription
Score 4+:
- Appropriate to offer antibiotics
List some complications of tonsillitis
- Peritonsillar abscess (quinsy)
- Chronic tonsillitis
- Otitis media (if spreads to inner ear)
- Scarlet fever
- Rheumatic fever
- Post-streptococcal glomerulonephritis
- Post-streptococcal reactive arthritis
List some common viruses and bacteria responsible for tonsillitis
Viral:
- Rhinovirus
- Adenovirus
- Enterovirus
- EBV
Bacterial:
- Group A strep
- Strep pneumoniae
- Haemophilus influenzae
- E.Coli
List some causes of pain in the throat
- URTI, influenza, COVID-19, EBV
- Tonsillitis
- Pharyngitis
- Trauma e.g. recent intubation
- Malignancy e.g. thyroid, oesophageal, apical lung cancer / oral mucositis
- Allergic rhinitis with post-nasal drip
- GORD
- Certain medications e.g. cytotoxic drugs, Carbimazole, Clozapine
List some causes of dysphagia (difficulty swallowing)
Physical:
- Congenital malformation
- Tumour in GI tract e.g. oesophageal cancer
- Oesophageal strictures
- Pharyngeal pouch
Neurological:
- Head injuries
- MS
- Myasthenia gravis
- CNS tumors
- ALS (amyotrophic lateral sclerosis)
- Supranuclear palsy
Other:
- Sjögren syndrome (via xerostomia)
- Limited cutaneous systemic sclerosis
- Medications e.g. antipsychotics, bisphosphonates
List some differentials for neck swellings (midline, off centre and lymphadenopathy)
Midline:
- Thyroid mass e.g. goitre or malignant (WON’T move on tongue protrusion)
- Thyroglossal cyst duct (will move on tongue protrusion)
Off centre:
- Branchial cyst
- Salivary gland pathology e.g. inflammation or stones
- Haematoma (post-surgical)
Lymphadenopathy:
- Reactive (secondary to infection) e.g. EBV
- Malignancy e.g. local H&N cancer, lymphoma, leukaemia
- Rheumatological conditions e.g. SLE
List some differentials for hoarse voice
Involvement of recurrent laryngeal nerves
- Laryngeal nodules
- Laryngitis
- Supraglottitis and epiglottitis
- Invasive malignancy e.g. laryngeal cancer, thyroid cancer, apical lung cancer
- Post-surgical
- Thoracic aortic aneurysm
- Neurological e.g. MS, stroke
Retropharyngeal abscess - state the following:
- Presentation
- Investigations
- Management
Presentation:
Common in children after a recent URTI
- Rigid neck
- Dysphagia
- Odynophagia (pain on swallowing)
- Systemically unwell +/- airway compromise
Investigations:
- CT neck
Management:
- ABCDE approach with priority of maintaining the airway
- IV antibiotics
- Surgery with incision and drainage
Ludwig’s angina - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Infection of space between floor of mouth and mylohyoid
- Commonly associated with dental infections
Presentation:
- Painful mouth
- Drooling
- Protruding tongue
- Swelling of floor of mouth
- Airway compromise
Investigations:
- CT neck
- Orthopantomograph (OPG)
Management:
- ABCDE approach with priority of maintaining the airway
- IV antibiotics
- Surgery with incision and drainage
Epiglottitis - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Acute inflammation and swelling of epiglottis
- Usually caused by infection, specifically Haemophilus influenza B (also streptococcus pneumoniae)
Presentation:
4 D’s!
- Drooling
- Dyspnoea (difficult breathe)
- Dysphagia (painful / difficult swallow)
- Dysphonia (muffled “hot potato” voice)
- Tripod position
- High fever
Investigations:
No examinations!
- Lateral x-ray shows thumbprint sign or can exclude foreign body
Management:
- Keep child as comfortable as possible, no examinations
- Immediate escalation to senior paediatrician and anaesthetist
- Most recover okay, but prepare for intubation or tracheostomy
- Once secure airway, IV antibiotics and Dexamethasone
Outline the investigation of choice for almost all neck lumps
Fine needle aspiration (FNA)
Unless it is a pulsatile mass!
Obstructive sleep apnoea - suggest some investigations and management steps
- Weight and height (calculate BMI)
- Thyroid function tests (hypothyroidism)
- Chest x-ray (lung disease)
- ECG (right sided ventricular failure)
- Sleep studies
Management:
- Weight loss advice
- CPAP
- Mandibular positioning devices
- Adenotonsillectomy in children
Outline differentials for a thyroid mass (knowing it’s thyroid tissue) and how they can be managed
Benign:
- Singular = colloid / cyst
- Multinodular = goitre
- Adenoma
Management: conversative, unless compressive symptoms then surgery
Malignant:
- Papillary adenocarcinoma (70%)
- Follicular carcinoma (20%)
- Medullary carcinoma
- Anaplastic carcinoma
Management: total thyroidectomy (unless anaplastic), plus radioiodine therapy for papillary and follicular
List some potential complications following thyroid surgery
Post-operative haematoma / haemorrhage - may lead to airway obstruction
Damage to recurrent laryngeal nerve - may lead to airway obstruction if bilateral
Hypocalcaemia
Acute sialadenitis - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Acute infection of the salivary glands (most commonly the parotid gland)
- Bacterial or viral
- Chronic sialadenitis is rare
Presentation:
- Pain/tenderness over affected gland
- Swelling/oedema over affected gland
- Hardening of gland (induration)
- Local erythema
Management:
- Regular hydration
- Warm compresses
- Analgesia
- Sialogogues
Sialolithiasis (salivary gland stones) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Formation of stones in the salivary ducts
- Leads to obstruction, pain and swelling
- Most common in the submandibular gland
Presentation:
- Pain and swelling over affected gland (worse prior to/during meals)
Investigations:
- Sialogram
- Ultrasound
Management:
Conversative with regular hydration, warm compresses, analgesia, sialogogues
Endoscopy
Radiological removal
Surgery to remove stones or salivary gland
Outline the main bacterial and viral causes of acute sialdenitis
Bacterial:
- Staph aureus
Viral:
- Mumps
- Coxsackievirus
- HIV
- Echovirus
