ENT Hot-desk Management

Question 1

Acute maxillary sinusitis:

Systemically Well

Answer 1

Home
Nasal steroids (fluticasone/beclametasone)
+/- Oral co-amoxiclav 625mg TDS

Question 2

Acute maxillary sinusitis:

Unwell

Answer 2

1. EXCLUDE PERIORBITAL CELLULITIS
2. Admit- IV Co-Amoxiclav 1.2g TDS
3. Washout

Question 3

Peri-orbital cellulitis

Answer 3

IMMEDIATE ESCALATION TO SpR
Joint care with Opthalmology
IV Co-amoxiclav

Question 4

Acute Ethmoiditis

Answer 4

IMMEDIATE ESCALATION TO SpR
Ophthalmology review 
CT head
IV Cefotaxime
? Book for washout

Question 5

Tonsillitis

Answer 5

Consider glandular fever- monospot test
Admit if: immunocomprimised, diabetic, SOB, stridorlous or septic.
If not- Initiate Portsmouth protocol

Question 6

Tonsillitis- Portsmouth protocol

Which patient groups trial medical managment?

Answer 6

1. Those who can swallow and do not have disproportionate pain
2. Those struggling to swallow or in pain WITH NORMAL LARYNGOSCOPY

Question 7

Tonsillitis- Portsmouth protocol

What is Trial management

Answer 7

IV Benzylpenecillin 1.2g (or 500mg Clary if allergy) 
IV Dex 4mg 
IV Paracetamol 1g
Diclofenac 
Difflam mouthwash
IVI 

Reassess after 2 hours.

Question 8

Tonsillitis- Portsmouth protocol

Reassessment criteria.

Answer 8

Can they swallow? Are they stable?

YES: Discharge with 7/7 Penicillin V / Clarithromycin 500mg, analgesia and info sheet

NO: Admit.

Question 9

Quinsy

Answer 9

ADMIT
Local Anesthetic
Aspiration with white needle
IV Co-amox/ Clari

Question 10

Ludwig’s Angina

Answer 10

ADMIT
Max Fax review
Airway stablisation ?emergency Trache
IVI
IV Gent (1mg/kg TDS), Co-Amox (1.2g TDS) and Metro (500mg TDS)
Dex 8mg
Lateral soft tissue neck XRay + AP/Lateral CXR

Question 11

Retrophayngeal abscess

Answer 11

ADMIT
Lateral soft tissue Xray neck
Airway management
IV access, bloods and cultures

Question 12

Epi/Supra glottitis

Answer 12

ADMIT
Alert CEPOD
Nasendoscopy in adults only
Cefotaxime 1g BD (50mg/kg if <11yrs)
Dexamethosone 8mg (150micrograms/kg BD in children)

Question 13

Anaphylaxis / Hereditary Angioedema

Answer 13

ADMIT
0.5ml 1:1000 adrenaline IM
200mg Hydrocortisone IV
4mg Piriton
IVI 
O2 
Airway support

Question 14

Post-tonsilectomy bleed

Answer 14

ADMIT 
Observations 
IVI + IV ?Abx? 
Hydrogen peroxide 3% mouthwash
Adrenaline soaked gauze 
Silver nitrate cautery 
Tranexamic Acid
- Alert CEPOD +/- major hemorrhage protocol

Question 15

Epistaxis

Answer 15

Check Airway
Check haemodynamics
1. Compression 15mins
2. Lidocaine plug + compression
3. Examination
4. Cautery of visible bleeding points
#IF STILL BLEEDING AT THIS POINT WILL NEED ADMISSION #
5. Insert Pack
6. Bolster with swab
7. Tranexamic acid
8. IV Access and BLoods including G&S
#IF STILL BLEEDING AT THIS POINT ALERT SpR#
9. Bilateral or Posterior packing
10. Foley Catheter
#IF STILL BLEEDING ALERT CEPOD- FOR LIGATION#

Naseptin

If >24hrs packed PO Abx

Question 16

Foreign Body in Nose

Answer 16

Is it Caustic or alive?
NO- Emergency clinic r/v
YES- Attempt removal immediately

1. “Mothers kiss”
2. Otravine Nasal spray + 2nd “Mothers Kiss”
3. Attempted manual removal- suction, tilleys or ear hook
4. If unsuccesful list for theatre

Question 17

Foreign Body in Ear

Answer 17

Is it Caustic or alive?
NO- Emergency clinic r/v
YES- Attempt removal immediately (Poor oil in to kill living FBs)

1. Suction.
2. Crocodile Forceps
3. Wax Hook

If unsuccessful list for theater

Question 18

Foreign Body Sensation in Throat

Answer 18

Protect airway
Inspect oropharynx.
If visible attempt manual removal under local anesthetic
Lateral Soft x-ray of neck
Flexible Nasal Endoscopy
Examine to exclude perforation.
If nothing identified- D/C to review in 1/52

Question 19

Confirmed Foreign body in throat

Answer 19

IS it sharp/ hard or caustic? Is It compromising airway?
YES: List for theater
NO: Attempt conservative management.

1. Buscopan 20mg x 2 (30 mins apart)
2. Full fat coke
3. Analgesia
4. NMB (?sips) overnight
5. Endoscopy to push down/ remove Mane

Question 20

?Perforation from FB in throat

Answer 20

Look for: 
-Chest/ shoulder or back pain
-Surgical Emphysema 
-Fever
If present= CT, antibiotics and list for theater

Question 21

Sudden (<3 days) Hearing loss

Answer 21

CONSIDER CENTRAL CAUSE

1. Audiogram
2. 7/7 PO Prednisolone 60mg + PPI Cover
3. Bloods- including autoimmune screen
4. Medication review
5. Repeat Audogram in 2/52
6. O/P MRI

Question 22

Snoring

NEVER URGENT

Answer 22

Perform Epworth scoring:
<10 Get GP to refer to dentist
>10 refer to sleep nurse

Question 23

Stridor unkown cause

Answer 23

CALL SpR IMMEDIATELY
IV Hydrocortisone 8mg
Oxygen
Nasendoscopy

Question 24

Auricular Haematoma

Answer 24

1. Attempt needle aspiration
2. Incision and evacuation on lateral pinna.
3. Pressurised betadine dressing + sutures
4. 5/7 Flucloxocillin 500mg QDS

Question 25

Traumatic TM perforation

Answer 25

EXCLUDE PERI-LYMPH LEAK 1. Prophylactic amoxicillin 500mg TDS 5/7 2. Water precautions 3. O/P Audiogram 2 weeks

Question 26

Fractured Nose

Answer 26

EXCLUDE SEPTAL HAEMATOMA SH NOT present: O/P review in 10 days SH PRESENT: Admit, List for theater, antibiotics.

Question 27

Bells Palsy

Answer 27

Exclude ALL other causes of CN VII Palsy Steroids 1/7 Eye Care Review in clinic in 1/12

Question 28

Otitis Media

Answer 28

CHECK FOR NEUROLOGICAL COMPLICATIONS Oral Amoxicillin Topical Abx Simple analgesia

Question 29

Otitis Externa

Answer 29

``` Swab C&S Microsuction debris Insert popewick if necessary Topical antibiotics + Steroids (Gent if TM visualised, Cipro if not 14/7) PO antibiotics if systemically unwell. ```