Week 23 - ear, nose and throat Flashcards
Sore throat
Only about 5% of people with sore throat go to their GP
->Most sore throats (90%) due to viral infection
->Majority self-limiting whether viral or bacterial
->Often associated with other symptoms of a cold
->Antibiotics make no difference to majority of bacterial sore throats – however, still one of the main reasons for prescribing in the UK
Questions to ask (sore throat)
Age: children of school age more likely to have streptococcal infection, young children more likely to develop croup
Duration: usually resolves within a week, longer than this may warrant referral
Severity: if extremely painful after 24-48h, especially when other symptoms of a cold are absent, will warrant referral
Associated symptoms: cough and cold, aches and pains expected, but difficulty swallowing and hoarseness may be signs of more serious condition
Current medication: especially inhaled steroids, carbimazole and immunosuppressants
Things to exclude (sore throat)
-Laryngitis (sore throat and diminished voice) in babies and young children may lead to croup (difficulty breathing and stridor)
-Long-standing hoarseness (> 3 weeks, esp. without other symptoms) may also be a sign of laryngeal cancer
-Glandular fever (caused by Epstein-Barre virus) presents with severe sore throat and dysphagia, swollen lymph glands, malaise, fever, creamy exudate on tonsils
-Oral thrush
OTC treatment
->Simple analgesia, e.g. paracetamol, ibuprofen, aspirin (>16 only)
->Anti-inflammatory, anaesthetic and antiseptic lozenges and sprays
When to refer (A&E)
Urgent referral (including to A&E if very unwell):
-Respiratory distress
-Drooling
-Systemically very unwell
-Unable to swallow
-Difficulty opening mouth
-Muffled voice – or making a high-pitched sound as they breathe (stridor)
-Dehydrated or unable to take fluids
-Signs of being systemically unwell and at risk of immunosuppression
When to refer (GP)
-Persistent symptoms that haven’t improved after a week
-Absence of a cough
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Oral thrush (oral candidiasis)
Infection of the mouth caused by candida albicans
->Can be treated in pharmacy from age of 4 months
-Common in babies in first few weeks of life
->In older children and adults usually associated with antibiotics or inhaled corticosteroids (or underlying disease involving
immunocompromise, e.g. diabetes)
Accompanying symptoms (oral thrush)
Babies:
-Do not want to feed
-Nappy rash
Older children and adults:
-Cracks at corners of mouth (angular cheilitis)
-Not tasting things properly
-Unpleasant taste in mouth
-Pain/soreness
-Difficulty eating and drinking
Treatment (oral thrush)
Antifungal, miconazole
Applied qds in adults and children >6years, bd for younger
->Interacts with a number of other medicines -> including warfarin and statins
When to refer (oral thrush)
-Babies under 4 months
-Older children and adults without an obvious cause
-Recurrent or persistent infection
-Failed medication
-Patients taking an interacting medicine that can’t be stopped, e.g. warfarin
Ear wax, otitis externa and otitis media
->Treatment of common problems often straightforward, but difficult to examine the ear unless trained and equipment (otoscope, etc.) available
->Much needs to be referred
Ear wax
Normal physiological substance (cerumen) -> is antibacterial and cleans, lubricates and protects ear canal -> excessive build-up of hardened wax can affect some people
Symptoms:
-Sensation of blockage
-Temporary deafness
-Discomfort (not pain)
-Tinnitus
-Rarely, dizziness/nausea
Treatment (ear wax)
Do NOT use earbuds to try to remove wax
->Olive oil, almond oil (not if pt allergic) or sodium bicarbonate drops recommended
-Warm drops to room temperature before use
->A few drops into the ear with affected ear uppermost, staying like this for a few minutes after use -> use qds for 3-5 days
Otitis externa (OE)
Inflammation and infection of skin in the ear canal
->1 in 10 people affected at some point in life
->May be localised (e.g. a boil) or diffuse
Symptoms:
-Localised – severe pain
-Diffuse – pain, itching, hearing loss, discharge
-Suspected OE should be referred
Otitis media (OM)
Infection of the middle ear compartment
->Middle ear normally airtight other than via Eustacian tube into back of throat
->Viral cold can block tube and lead to fluid build-up in middle ear (may be secondarily infected with bacteria)
->Best treatment is with analgesia
->Antibiotics do little even if bacterial infection
Refer if: under 2 yrs, no resolution in a few days,
systemically unwell, discharge from ear
Glue ear
Also known as “serious otitis media”
-OM that persists or is recurrent
-Can be bilateral
-Can cause deafness, which in turn affects language development
->Often spontaneously resolves -> sometimes requires operation to remove fluid
Motion sickness
Symptoms:
-Nausea with or without vomiting
-Pallor
-Cold sweats
-Hypersalivation
Avoidance measures (motion sickness)
-Elevated seating position
-Look at horizon
-Fresh air
-Keep cool
-Breaks
-Avoid stimuli
-Distractions
Treatments (non-pharmacological) - motion sickness
-Wrist bands for pressure points
-Ginger
Treatments (pharmacological) - motion sickness
Hyoscine hydrobromide:
-From age 3 OTC (BNFc says age 4 for motion sickness)
-Antimuscarinic adverse effects
-Short-acting (up to 4 hours)
Scopoderm patches:
-Over 10 years
-Apply 5-6 hours before journey (or night before)
-Lasts for up to 3 days, so remove when journey finished
-Adverse effects may last for 24 hours after removal
Cinnarizine:
-Min. age 5 years
-Intermediate acting – up to 8hours
Promethazine
-Min. age 2 years
-Long-acting – more than 8 hours
Allergic rhinitis
Allergic rhinitis - general term
-> Defines nasal inflammation in response to histamine
-Up to 25% of UK population affected – rising
-Onset usually in children and young adults
-May be past history of atopic allergy
-Patient may have suffered before
-May develop asthma
-Pollen calendar / hayfever
Symptoms (allergic rhinitis)
-Rhinorrhoea/nasal congestion / nasal itching / sneezing
-Eye symptoms -> red, swollen, watery
Non-pharmacological treatment (allergic rhinitis)
When the pollen count is high the person should:
-Avoid pollen by closing windows, wearing wraparound sunglasses and avoiding grassy areas particularly during early morning, evening and night
-Avoid drying clothes outside
-Apply Vaseline around their nostrils to trap the pollen
-Shower and wash their hair after being outdoors to remove pollen
-Vacuum regularly and dust with a damp cloth
Pharmacological treatment (allergic rhinitis)
Stepped approach:
->For people with occasional symptoms of allergic conjunctivitis, children aged
2–5 years and people who prefer an oral formulation treat with an oral antihistamine
->If the predominant symptom is sneezing or nasal discharge treat with an oral antihistamine
->For people with more persistent symptoms, and predominant symptom is nasal blockage, treat with an intranasal corticosteroid (people over 18 years [OTC])
->For people with signs of allergic conjunctivitis sodium cromoglicate eye drops may provide additional relief
When to refer
-Wheezing/SoB (shortness of breath)
-Ear pain
-Facial pain
-Person is pregnant or breastfeeding
-Uncontrolled symptoms continue after 2–4 weeks despite correct use of medication
-Urgent resolution of severe symptoms affecting quality of life is required
-Person is a child under 2 years requiring treatment
-There is nasal blockage in the absence of rhinorrhoea, nasal itch and sneezing
-There is unilateral nasal discharge, especially in a young child, to check for a trapped foreign body
