Week 1 Flashcards
Sore Throat - Key History?
- First determine whether the patient has a sore throat, a deep pain in the throat or neck pain.
- Enquire about relevant associated symptoms such as a metallic taste in the mouth, fever, upper respiratory infection, postnasal drip, sinusitis, cough and other pain such as ear pain.
- Note whether the patient is an asthmatic and uses a steroid inhaler or is a smoker or exposed to environmental irritants.
Sore Throat - Key Examination?
- On inspection note the general appearance, look for toxicity, the anaemic pallor of leukaemia, the nasal stuffiness of infectious mononucleosis or the halitosis of a streptococcal throat.
- Palpate the neck for soreness and lymphadenopathy and check the sinus area.
- Then inspect the oral cavity and pharynx
Sore Throat - 5 Key Investigations?
- throat swab
- FBE
- mononucleosis test
- blood sugar
- biopsy of suspicious lesions.
Evaluation of acute pharyngitis in adults?
Pediatric sore throat: Initial approach?
Ear Pain (Otalgia)
- Probability diagnosis
- Serious disorders not to be missed
- Pitfalls (often missed)
- Masquerades
- Is the patient trying to tell me something?
Ear Pain (Otalgia) - Key History?
Assess the site of pain and radiation, details of the onset of pain, nature of the pain, aggravating or reliving factors and associated features such as vertigo, tinnitus, sore throat and irritation of the external ear. Ask about trauma, especially the use of a cotton bud to clean the ear.
Ear Pain (Otalgia) - Key Examination?
- The external ear with manipulation of the ear.
- Check helix for chondrodermatitis nodularis helicus.
- Palpate the face and neck to include the parotid glands, regional lymph nodes and skin and temporomandibular joint (TMJ).
- Inspect both empty ear canals and tympanic membrane (TM) with the auroscope using the largest possible earpiece.
- Look for causes of referred pain: cervical spine, nose, postnasal space and mouth including teeth
Ear Pain (Otalgia) - Key Investigations?
- Consider hearing tests, audiometry
- Any ear discharge for MC but swabs of no value if the TM is intact
Deafness and Hearing Loss
- Probability diagnosis (6)
- Serious disorders not to be missed (10)
- Pitfalls (often missed) (9)
- Masquerades (3)
- Is the patient trying to tell me something?
Deafness & Hearing Loss - Key History?
Onset and progression of any deafness, noise exposure, drug history, swimming or diving, air travel, head injury and family history. A recent or past episode of a generalised infection would be relevant and the presence of associated aural symptoms such as ear pain, discharge, tinnitus and vertigo. Enquire about the effect of noise.
Deafness & Hearing Loss - Key Examination?
- Inspect the facial structures, skull and ears and the ear with an otoscope. Ensure that the external auditory canal is clean
- Perform simple office hearing tests including tuning fork tests
Deafness & Hearing Loss - Key Investigations?
- Audiometry and tympanometry
- Swab of any ear discharge for M&C
5 Ototoxic drugs?
Ototoxic drugs:
1. Alcohol
2. Aminoglycosides e.g. streptomycin, neomycin, gentamicin, tobramycin
3. Chemotherapeutic agents
3. Quinine
4. Salicylates/aspirin excess
5. Diuretics e.g. ethacrynic acid, frusemide.
Cough
- Probability diagnosis (6)
- Serious disorders not to be missed (4)
- Pitfalls (often missed) (7)
- Masquerades (1)
- Is the patient trying to tell me something?
Cough - Key History?
Determine the nature of the cough, especially associated symptoms such as the nature of the sputum, breathlessness, wheezing and constitutional symptoms. Haemoptysis See ‘Haemoptysis (in adults)’. History of smoking habits, past and present, and occupational history are essential. Past history, especially respiratory and drug intake.
Cough - Key Examination?
- General examination including a search for enlarged cervical or axillary glands.
- Careful examination of the lungs and cardiovascular system with inspection of sputum.
Cough - 4 Key Investigations?
- FBE/ESR/CRP
- Sputum cytology and culture
- Respiratory function tests
- Plain CXR and others as appropriate
Cough - 4 Key Investigations?
- FBE/ESR/CRP
- Sputum cytology and culture
- Respiratory function tests
- Plain CXR and others as appropriate
3 Red Flags for Tonsillitis and Sore Throat?
What is involved in the assessment of a patient presenting with Tonsillitis/Sore Throat?
Discuss the acute management of a patient presenting with Tonsillitis/Sore Throat?
Management of recurrent GAS throat infections?
Management of recurrent tonsillitis?
- When would you request emergency assessment of a patient with a sore throat/tonsillitis?
- When would you request an acute ENT assessment of a patient with a sore throat/tonsillitis?
- When would you request a non-acute ENT assessment of a patient with a sore throat/tonsillitis?
2 Red flags for hearing loss in adults?
Assessment of an adult who presents with hearing loss? (12)
Management of an adult who presents with hearing loss? (4)
When would you request the following in an adult presenting with hearing loss?
- emergency assessment?
- acute ENT assessment?
- non-acute ENT assessment?
What is Sinusitis?
Definitions:
- Pansinusitis?
- Acute sinusitis?
- Subacute sinusitis?
- Chronic sinusitis?
- Recurrent Acute sinusitis?
- Rhinosinusitis?
Rhinosinusitis is a mucosal inflammation of both the paranasal sinuses and adjacent nasal cavities.
Which symptoms characterise Rhinosinusitis?
How does Chronic rhinosinusitis differ from acute rhinosinusitis?
Which contributing factors is Chronic rhinosinusitis usually related to?
What is the epidemiology of sinusitis?
What Clinical features of acute rhinosinusitis indicate spreading bacterial infection?
What is the aetiology and risk factors of sinusitis?
What is the pathophysiology of sinusitis?
Clinical Features of Acute rhinosinusitis?
How can you distinguish between acute viral and bacterial rhinosinustis?
The signs and symptoms of acute viral and bacterial rhinosinusitis overlap considerably, especially during the first 3 to 4 days of illness. If the patient presents in the first 3 to 4 days of illness, manage as for viral rhinosinusitis, as this is the most likely cause of symptoms. After the first 3 to 4 days of illness, the clinical course may help to distinguish between acute viral and bacterial rhinosinusitis.
Describe an approach to a patient with acute rhinosinusitis?
What are Nasal Polyps?
- Definition?
- Risk factors?
- Clinical features?
- Special form: choanal polyp?
Nasal polyps
- Diagnostics?
- Differential diagnosis?
- Treatment?
What is Primary ciliary dyskinesia?
- Definition?
- Clinical features?
Primary ciliary dyskinesia?
- Diagnostics?
- Treatment?
What are the general principles in the diagnosis of sinusitis?
What imaging modalities can be used in the diagnosis of sinusitis?
List 5 red flags in sinusitis?
Describe an assessment of a patient who presents with rhinosinusitis?
Describe an approach to the treatment of rhinosinusitis?
Which 4 medications are involved in the Symptomatic therapy for acute rhinosinusitis?
Discuss the indications and regimens for antibiotic therapy for acute sinusitis?
Discuss the initial management of Chronic rhinosinusitis without nasal polyps?
Discuss the management fo Chronic rhinosinusitis with nasal polyps?
Discuss the indications and objectives of surgery for patients with sinusitis?
What are the possible complications of sinusitis?
How is Acute rhinosinusitis (ARS) managed?
How is Chronic rhinosinusitis (CRS) managed?
When should you refer to ENT in a patient with sinusitis?
What is Acute tonsillitis?
- Epidemiology?
- Peak incidence:
- Acute viral tonsillopharyngitis: children < 5 years and young adults
- Acute GAS tonsillopharyngitis: children aged 5–15 years; rare in children aged < 2 years
- Peak season: Acute GAS tonsillopharyngitis most commonly occurs in winter and spring.
What is the aetiology of Acute tonsillopharyngitis and of Recurrent tonsillopharyngitis and chronic tonsillitis?
What are the clinical features of Acute bacterial tonsillopharyngitis?
What are the clinical features of Acute viral tonsillopharyngitis?
What are the red flag features of tonsillopharyngitis?
Describe an approach to the diagnosis of tonsillopharyngitis?
Describe the assessment of a patient who presents with Tonsillitis and Sore Throat?
Describe the role of Rapid strep test in suspected acute bacterial tonsillopharyngitis?
- Modality?
- Indications?
- Procedure?
- Findings?
What is the Modified Mentor Score?
Discuss the acute management of a patient with Tonsillitis and Sore Throat?
What are the Recommended antibiotic regimens for acute GAS pharyngitis?
- If possible, collect a throat swab for culture to confirm S. pyogenes infection before starting antibiotic therapy.
- S. pyogenes remains highly susceptible to phenoxymethylpenicillin. A 12-hourly dosing regimen for phenoxymethylpenicillin is effective for the treatment of streptococcal pharyngitis or tonsillitis, and is preferred over more frequent dosing regimens because of improved adherence.
- Amoxicillin has traditionally not been recommended for sore throat because of concern about an increased incidence of rash if the patient has undiagnosed Epstein–Barr virus (EBV) infection. However, evidence suggests that amoxicillin does not significantly increase the incidence of rash in this setting. Amoxicillin does, however, expose patients to unnecessary broader-spectrum treatment compared to phenoxymethylpenicillin. Therefore, it is not recommended first-line for the treatment of streptococcal pharyngitis and tonsillitis, but has a limited role in children who are unable to tolerate the liquid formulation of phenoxymethylpenicillin.
What is the management of recurrent GAS throat infections?
What is the management of recurrent GAS throat infections?
What are the indications for tonsillectomy?
What are the possible complications of tonsillitis?
What is Conjunctivitis?
What are the different subtypes of conjunctivitis?
Allergic Conjunctivitis?
- One of the most common causes of noninfective conjunctivitis is allergic conjunctivitis. This results from a local response to an allergen, and includes seasonal (typically in spring and autumn) and perennial conjunctivitis, and contact hypersensitivity reactions (eg to preservatives in eye drops and contact lens solutions). The primary diagnostic symptom is itch with watery eyes. In seasonal and perennial conjunctivitis, symptoms are usually bilateral.
- Prompt referral to an ophthalmologist is required for conjunctivitis that is associated with severe or worsening symptoms (eg significant pain, reduced vision or photophobia) to exclude more serious diagnoses such as keratitis.
Viral conjunctivitis?
- Viral conjunctivitis is most commonly caused by adenovirus and is frequently associated with a viral upper respiratory tract infection and preauricular lymphadenopathy. Diagnosis is clinical. Symptoms of conjunctival injection (red eye), watery discharge and irritation are initially unilateral but often become bilateral.
- Symptomatic treatment is recommended, including cold compresses several times a day and lubricant eye drops. Inform patients of hygiene measures to reduce the spread of infection. Avoid the use of topical corticosteroids without advice from an ophthalmologist.
- There is no role for topical antibiotics such as chloramphenicol.
- There is no role for topical chloramphenicol in viral conjunctivitis.
- Ocular infection with herpes simplex virus and herpes zoster virus can also cause conjunctivitis. Seek expert advice from an ophthalmologist.
Bacterial conjunctivitis?
- Bacterial conjunctivitis can be primary or secondary (eg to nasolacrimal duct obstruction).
- Cases typically present with conjunctival injection (red eye), purulent discharge and crusting of the eyelids.
- Common pathogens include Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae (especially in children younger than 5 years who are not fully vaccinated, often causing ‘conjunctivitis–otitis syndrome’).
- Conjunctivitis caused by Neisseria meningitidis can precede or accompany systemic disease; treatment is as for invasive meningococcal disease.
- Many cases of bacterial conjunctivitis resolve within 7 days without treatment.
Clinical Features of conjunctivitis?
How is conjunctivitis diagnosed?
What are 3 red flags for Infective Conjunctivitis?
What is involved in the assessment of a patient with infective conjunctivitis? (7)
What is involved in the assessment of a patient with allergic conjunctivitis?
What is the management of infective conjunctivitis?
What is the management of allergic conjunctivitis?
- Supportive therapy?
Discuss the antibiotic regimen recommended for acute bacterial Conjunctivitis?
When would you refer a patient with infective conjunctivitis?
When would you refer a patient with allergic conjunctivitis?
What are some differentials for conjunctivitis?
What is Trachoma?
What is Otitis Externa?
- Acute vs. Chronic?
- Acute otitis externa (AOE): inflammation of the EAC lasting < 6 weeks
- Chronic otitis externa (COE): inflammation of the EAC lasting at least 6 weeks to 3 months
What is the aetiology of Acute otitis externa?
- Infectious cases?
- Non-Infectious cases?
- Risk factors?
Pseudomonas aeruginosa and Staphylococcus aureus are the most common causes of acute diffuse otitis externa; other bacterial causes are much less common. Fungal infection (otomycosis) occurs less frequently than bacterial infection, and usually follows prolonged antibiotic use. Candida or Aspergillus species are the most common fungal pathogens.
What are the 6 red flags for otitis externa?
5 Symptoms of Otitis Externa?
Examination findings in Otitis Externa? Otoscopic findings?
Image - There is swelling and mild erythema of the external auditory canal and auricle. Purulent discharge from the external auditory canal is visible. The auditory canal appears to be obstructed. These findings are consistent with otitis externa.
Describe the assessment of a patient with otitis externa? (6)
5 Differential diagnosis of otitis externa and their clinical features?
Discuss the management of Otitis Externa?
Approach
1. Initiate supportive therapy as needed, e.g., analgesia, ear wick, aural toilet.
2. Evaluate for indications for systemic antibiotic therapy in AOE and start if present.
3. For uncomplicated AOE, initiate topical therapy for OE.
4. Antibiotic (ofloxacin, ciprofloxacin, or gentamicin) or antiseptic ear drops.
5. Preparations may be combined with glucocorticoids.
6. If patients do not respond to initial topical therapy, consider alternative diagnoses such as allergic contact dermatitis from an ototopical agent, otomycosis, or MOE.
Discuss the Antimicrobial regimens for acute diffuse otitis externa?
If possible, avoid products containing an aminoglycoside (eg framycetin, neomycin) in patients with a perforated tympanic membrane or a tympanostomy tube in situ because of the risk of inner ear damage; however, this complication appears to be rare. It is also preferable to avoid aminoglycosides if the tympanic membrane cannot be visualised, in case it is perforated. Instead, use flumetasone+clioquinol ear drops (as above) or, if an alternative is necessary, ciprofloxacin+ hydrocortisone ear drops. If aminoglycoside-containing products cannot be avoided, they can be used with caution because treatment is of short duration.
When are systemic antibiotics indicated for otitis externa? What regimen would you use?
What are the preventive strategies for otitis externa?
What is Acute Otitis Media? Epidemiology?
- Highest incidence between 6–24 months of age
- Approx. 60–80% of children ≤ 3 years old experience AOM at least once. The incidence of AOM has been declining since the introduction of the pneumococcal and influenza vaccinations.
- Slightly higher incidence in boys
What is the pathophysiology of Acute otitis media?
What is the aetiology of Acute Otitis Media?
List 9 Risk factors associated with acute otitis media?
Clinical Findings in Acute Otitis Media?
- 4 General symptoms?
- 6 Typical symptoms in infants?
- Otoscopic findings?
General symptoms
1. Otalgia/earache, commonly described as throbbing pain
2. Hearing loss in the affected ear
3. Fever
4. Otorrhea in the case of a ruptured tympanic membrane (TM)
Typical presentation in infants
1. Irritability
2. Incessant crying
3. Refusal to feed (anorexia)
4. Repeatedly touching the affected ear
5. Fever and febrile seizures
6. Vomiting
What is involved in the assessment of a patient with acute otitis media?
What are the results of Weber and Rinne test in patient’s with Acute Otitis Media?
Which other diagnostics would you consider?
Tuning fork test
- The Weber test and Rinne test can be performed to verify conductive hearing loss secondary to an effusion.
- Weber test: Sound localizes to the affected ear.
- Rinne test: Air conduction is impaired in the affected ear, while bone conduction remains intact.
Discuss an approach to the management of Acute Otitis Media?
Adequate and regular analgesia is the mainstay of acute otitis media treatment. For most children, antibiotic therapy can be safely withheld.
Discus the role of Antibiotics in the treatment of acute otitis media?
- Indications?
- Topical vs. Systemic?
What would you say to a patient (or parent) who requests antibiotics for the treatment of a probable ENT viral illness?
What is the suggested antibiotic regimen for treatment of acute otitis media in indicated patients?
When should you refer a patient with acute otitis media?
Which surgical procedures are available for the treatment of otitis media? When are they indicated?
