Misc ENT Conditions

 

• Sore throat

  Definition

  Encompasses pharyngitis, tonsillitis (palatine tonsil infection), or a combination of both. The two can be hard to distinguish clinically and their management is essentially the same.

  Causes

  Common causes:

  • Upper respiratory tract viruses e.g. rhinovirus, coronavirus, parainfluenza virus.
  • Around 20% are due to Group A Strep (GAS).

  Rarer causes:

  • Viral: infectious mononucleosis (EBV), influenza, adenovirus (pharyngoconjunctival fever), HSV1 (with palate vesicles), Coxsackie A, HIV seroconversion.
  • Bacterial: gonorrhea (from oral sex), Chlamydophila pneumoniae, Mycoplasma pneumonia, diphtheria.

  Epidemiology

  • Peak age groups: 5-10 years and 15-25 years. Rare <3 years.
  • GAS is commoner in kids than adults.

  Associated symptoms

  • Odynophagia (painful swallow).
  • Coryza
  • Tonsillar exudate, enlargement, and erythema.
  • Fever
  • Anterior cervical lymphadenopathy.
  • Headache
  • Abdo pain, nausea, and vomiting.
  • Lethargy may suggest infectious mononucleosis, especially if lasting >1 week.

  Investigations

  • Not routinely needed.
  • Throat swabs for culture and rapid Strep antigen tests have poor sensitivity, and cannot differentiate between active GAS infection and coincidental carrier status.
  • However, throat swabs can be considered for severe, recurrent, or atypical cases.

  Management

  Symptomatic relief:

  • Paracetamol (1st line in kids) or ibuprofen (1st line in adults).
  • Increasing evidence that single-dose dexamethasone is safe and effective.

  Antibiotics:

  • Most cases are viral and will not benefit from antibiotics.
  • Decision to use antibiotics can be guided by Modified Centor criteria, CENTA: tender anterior Cervical lymph nodes, tonsillar Exudate, No cough, ↑Temperature, Age 3-14. Presence of 4-5 suggests 50% chance of GAS infection and hence possible benefit from antibiotics.
  • Even if GAS is the cause, most cases resolve without complications and antibiotics only provide moderate symptomatic relief.
  • Recommended antibiotics: phenoxymethylpenicillin (pen V) for 5-10 days, macrolide if penicillin allergic.

  Tonsillectomy for recurrent, severe tonsillitis.

  Complications

  • Otitis media.
  • Acute sinusitis.
  • Peritonsillar abscess (Quinsy): fever, sore throat, difficult mouth opening (trismus), dysphagia, referred otalgia, and tonsillar displacement towards the midline.
  • Retropharyngeal abscess. Commoner in children, who may hyperextend neck to aid breathing.
  • Sore throat may be an early sign of scarlet fever.
  • Autoimmune complications of GAS: rheumatic fever, guttate psoriasis, post-streptococcal glomerulonephritis, PANDAS (Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections).

• Otitis media

  Pathophysiology

  • Middle ear inflammation.
  • Pathogens: Strep. pneumo, nontypeable H. influenzae, Moraxella.
  • 75% occur <10 years old, especially 6-18 months.

  Risk factors

  • Smoking
  • URTI
  • Bottle-feeding and dummy use.
  • Adenoids
  • Anatomical malformations.

  Signs and symptoms

  Acute otitis media:

  • Sudden pain and fever.
  • Inflammed, bulging ear drum, or purulent discharge and resolution of pain if it has burst.
  • May follow URTI.
  • Other possible symptoms: irritability, anorexia, and vomiting.

  Chronic otitis media:

  • Several months of symptoms.
  • Fluid discharge.

  Management

  • Usually self-resolves within 3 days, but can last up to 1 week.
  • Consider amoxicillin for 5 days if: perforated tympanic membrane (and/or discharge in ear canal), ≥4 days symptoms, or bilateral OM <2 years old.

  Complications

  • Glue ear.
  • Chronic suppurative otitis media: foul discharge, ↓hearing, drum perforation
  • Infection spread: mastoiditis, petrositis, labyrinthitis, meningitis.
  • Facial palsy.
  • Abscess

• Otitis externa

  Pathophysiology and epidemiology

  • Inflammation of the external ear canal, usually due to infection with Staph. aureus or Pseudomonas aeruginosa, or non-infectious dermatitis (contact or seborrheic).
  • Can be acute (<3 weeks) or chronic (>3 months).
  • Affects any age, but commonest at 7-12.

  Presentation

  Itchy and painful external ear. Specific presentations are:

  • Localized OE: folliculitis or furuncle, presenting as swelling which may have yellow centre.
  • Diffuse OE (aka swimmer's ear): widespread scaly, inflamed skin.
  • Malignant OE (aka necrotizing otitis): rare but severe P. aeruginosa infection in immunocompromised or diabetics, with severe pain, discharge, hearing loss, tissue destruction, and spread to bone.

  Investigations

  Swab for culture is rarely needed, except in malignant OE.

  Management

  • Localized OE often self-resolves without treatment. In rare cases, may need oral antibiotics (for spreading cellulitis, fever), or incision and drainage (for large, painful, swelling).
  • Diffuse OE: topical antimicrobial (neomycin, gentamycin, ciprofloxacin) and/or corticosteroid, which can be in combination product e.g. neomycin/dexamethasone/acetic acid (Otomize).
  • Malignant OE: ciprofloxacin PO/IV.
  • Self-care to prevent recurrence: keep ears clean and dry by keeping water/soap/shampoo out and using earplugs when swimming, and avoid cotton buds.

• Earwax

  Diagnosis

  Diagnose and treat earwax (cerumen) impaction when seen on otoscopy and (a) causing symptoms (e.g. hearing loss) or (b) preventing needed visualisation of tympanic membrane.

  Management

  Cerumenolytic eardrops:

  • Water-based (e.g. saline, acetic acid, sodium bicarbonate) or oil-based (e.g. olive oil).

  Aural irrigation if cerumenolytics insufficient:

  • Usually with water and syringe.
  • Can be clinician-administered or self-administered (e.g. with over the counter syringe bulb kit).
  • Infection and tympanic membrane perforation are both contraindications and potential complications.

  Manual removal by ENT specialist if irrigation insufficient:

  • Aural microsuction, forceps, curette, or hook.

• Nasal fractures

  A fracture of one of the paired nasal bones, usually distal, where bone is thinnest.

  Presentation

  • Visible deformity of the nose. Comparing to old photo (e.g. driver's license) can help if unclear.
  • Bruising and oedema of nose and periorbital tissue, developing over hours.
  • Epistaxis, which may present in isolation without obvious deformity.
  • Septal hematoma: red-purple swelling on nasal septum, usually bilateral. Always perform internal nasal exam (with Thudichum's speculum or pen torch) to check for this. May first require management of epistaxis and/or topical anaesthesia for proper examination.

  Investigations

  Imaging only indicated if other facial fractures suspected.

  Management

  • If there is no deformity, conservative management is possible.
  • If there is obvious deformity, fractures undergo closed reduction (manipulation under local or general anaesthesia). Immediate reduction may be difficult (due to swelling), so it is usually done by ENT as an outpatient within 10 days.
  • More extensive injuries (e.g. open fracture) or those not fixed with closed reduction, may require endonasal septorhinoplasty or external septorhinoplasty (open reduction).
  • Septal hematomas require urgent incision and drainage by ENT, as untreated they can lead to necrosis and saddle nose deformity.