Throat and nose

Question 1

Features of tonsillitis

Answer 1

• Sore throat
• Difficulty swallowing
• Pyrexia
• General malaise
• Halitosis
• Lymphadenopathy
• Exudative inflammation
• Enlargement of the tonsils

Question 2

Cause of tonsilitis

Answer 2

Usually caused by beta-haemolytic Streptococcus, Pneumococcus or Haemophilus influenzae. Sometimes it occurs secondary to to an initial viral infection.

Question 3

Treatment of tonsilitis (Patient can still eat and drink)

Answer 3

Mild

• Bed rest
• Simple analgesia
• Oral fluid replacement

Severe

• Oral antibiotics

Question 4

Treatment of tonsilitis if patient unable to eat and drink

Answer 4

• Admit
• IV fluids
• IV antibiotics (Benzylpenicillin + Metronidazole)
• Analgesia
• Consider dexamethasone

Question 5

Why should amoxicillin never be given for tonsilitis?

Answer 5

If the tonsilitis is caused by glandular fever the amoxicillin can result in a rash

Question 6

Investigations for tonsilitis

Answer 6

• FBC
• Monospot

Question 7

Complications of tonsilitis

Answer 7

• Febrile convulsions in children
• Infection may spread to form an abscess eg peritonsillar abscess (quinsy)

Question 8

Clinical features of peritonsillar abscess (quinsy)

Answer 8

• 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

Question 9

Why does trisumus occur in quinsy?

Answer 9

Due to inflammation of the pterygoid muscles

Question 10

Treatment of quinsy

Answer 10

• Decompression of the abscess by aspiration or incision (leads to instant symptomatic relief)
• Antibiotics

Question 11

What are the absolute indications for tonsillectomy?

Answer 11

• Suspected malignancy
• As part of another procedure eg uvulopalatopharyngoplasty
• Child with obstructive sleep apnoea syndrome

Question 12

Relative indication for tonsillectomy

Answer 12

• Recurrent acute tonsillitis (3 attacks per year for 2 years, or 5 attacks in 1 year)
• Chronic tonsillitis
• Previous quinsy
• Febrile convulsions

Question 13

What is Ludwig’s angina?

Answer 13

Infection of the submandibular space

Question 14

What is the most common cause of Ludwig’s angina?

Answer 14

It usually results from dental infection, Streptcoccus viridans is the most commonly isolated pathogen.

Question 15

Presentation of Ludwig’s angina

Answer 15

• 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

Question 16

Treatment of Ludwig’s angina

Answer 16

IV antibiotics (incision seldom finds any pus).

If airway is threatened, a tracheostomy may be required.

Question 17

Causes of epistaxis

Answer 17

Local causes:

• Idiopathic
• Trauma
• Infection
• Tumours

Systemic causes:

• Hypertension
• Anticoagulant drugs/NSAIDs
• Haematological diseases eg haemophilia, Von Willebrand’s disease

Question 18

Sites of Epistaxis?

Answer 18

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)

Question 19

Little’s area (also known as Kiesselbach’s plexus) is found on the anterior nasal septum and is an anastomosis of 5 arteries:

Answer 19

• anterior ethmoidal artery
• posterior ethmoidal artery
• sphenopalatine artery
• greater palatine artery
• septal branch of the superior labial artery

Question 20

History to ask in epistaxis

Answer 20

• 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

Question 21

Initial management of epistaxis

Answer 21

• 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.

Question 22

If conservative management of epistaxis is unsuccessful:

Answer 22

• 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

Question 23

Bloods that should be tested for epistaxis:

Answer 23

• FBC
• Clotting
• Group and save

Question 24

How would you manage a fractured nose?

Answer 24

• 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

Question 25

Symptoms of sinusitis

Answer 25

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

Question 26

What is acute sinusitis ?

Answer 26

Inflammation of the mucosal linings of the nasal passage and paranasal sinuses.

Question 27

Risk factors for acute rhinosinusitis:

Answer 27

* Cigarette smoke exposure (active or passive) * Air pollution exposure * Anatomical variations (such as septal deviation, nasal polyps, or sinus hypoplasia)

Question 28

The diagnosis of acute rhinosinusitis requires the sudden onset of two or more of the following symptoms:

Answer 28

* Nasal obstruction * Discoloured nasal discharge * Facial pain or pressure * Altered sense of smell

Question 29

Differential diagnosis for acute rhinosinusitis:

Answer 29

* Viral upper respiratory tract infection * Allergic rhinitis * Facial pain syndromes (eg migraines, cluster headaches, mid-segmental facial pain)

Question 30

Investigations for acute sinusitis

Answer 30

* 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

Question 31

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

Answer 31

1. Analgesia and nasal decongestants 2. Topical nasal steroids and oral antibiotics

Question 32

How would you differentiate between acute and chronic sinusitis?

Answer 32

The symptoms of acute sinusitis last for less than 12 weeks while the symtoms of chronic sinusitis last longer that 12 weeks.

Question 33

Risk factors for chronic sinusitis

Answer 33

* Asthma or atopy * Aspirin sensitivity * Ciliary impairment (eg cystic fibrosis or primary ciliary dyskinesia) * Smoking * Immunosuppression

Question 34

All cases of chronic rhinosinusitis should undergo which procedure?

Answer 34

Rhinoscopy

Question 35

Differential diagnosis for chronic sinusitis

Answer 35

* 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)

Question 36

To make a formal diagnosis of chronic sinusitis, nasal endoscopy is required. At least one of the following signs should be present:

Answer 36

* Mucosal swelling * Mucopurulent discharge * Mucosal occlusion of middle meatus * Nasal polyps

Question 37

Management of chronic sinusitis

Answer 37

* 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

Question 38

What is the aim of functional sinus surgery?

Answer 38

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.