Approach to sore throat

Sore throat: diagnostic strategy model

Probability diagnosis

• Viral pharyngitis
• Streptococcal tonsillitis
• Chronic sinusitis with postnasal drip
• Oropharyngeal candidiasis

Serious disorders not to be missed

• Cardiovascular 
• angina
• myocardial infarction 
• Neoplasia
• cancer of oropharynx, tongue
• Blood dycrasias (e.g. agranulocytosis, acute leukaemia)
• Severe infections:
• acute epiglottitis 
• peritonsillar abscess
• pharyngeal abscess
• diphtheria 
• HIV/AIDS

Pitfalls (often missed)

• Foreign body 
• Epstein-Barr mononucleosis
• Candida
• common in infants
• steroid inhalers
• STIs:
• gonococcal pharyngitis
• herpes simples (type II)
• syphilis
• Irritants (e.g. cigarette smoke, chemicals)
• Reflux oesophagitis --> pharyngolaryngitis
• Tonsilloliths
• Cricopharyngeal spasm
• Kawasaki disease
• Chronic mouth breathing 
• aphthous ulceration 
• Thyroiditis
• Rarities
• scleroderma
• behcet disease
• sarcoidosis 
• malignant granuloma 
• tuberculosis

Otitis Externa

Condition

• Otitis Externa

Definition

• Inflammation of the ear canal
• Can be caused by bacterial (e.g. streptococcus or pseudomonas) or fungal (aspegillos niger or candida species) 

History

• pain 
• discharge
• no recent upper respiratory tract infection
• predisposing factors: swimming, trauma, known narrow ear canal and past history of exostoses
• itchiness and skin scaling from ear canals this could suggest underlying skin diseases e.g. eczema

Examination

• otoscope 

DDx

• Malignant otitis externa 
• potentially life threatening infection of the external ear and skull base
• most commonly presents in elderly patients, diabetic patients and the immunocompromised 
• usually presents with unrelenting otalgia over several weeks 
• examination will show ear discharge, granulation tissue visible in the floor of the external ear canal. 
• There may be facial nerve or other lower cranial nerve involvement
• needs urgent referral 

Treatment

• Ear canal debridment
• Keep ear dry 
• Ear drops
• Oral analgesia
• Treatment of underlying skin disorder

References

1. Hawke library

Epistaxis

Condition

• Epistaxis 

Causes (Adapted from General Practice by John Murtagh)

• Local causes
• idiopathic
• intracranial tumours
• Rhinitis
• Trauma including nose picking
• URTI
• Common cold
• influenza
• Sinusitis
• Systemic causes
• Blood disorders
• Cardiovascular disorders
• arteriosclerosis
• hypertension
• Drugs: anticoagulants, aspirin, others
• Hereditary haemorrhagic telangiectasia
• Systemic febrile infections
• Toxic agents

History

• Establish volume of blood loss e.g. duration
• Try to identify cause e.g. medications, trauma, common cold, rhinitis, drug and alcohol and any other sources of bleeding
• Try to differentiate between anterior and posterior bleed

Examination

• Good light, suction and speculum with local decongestant and anaesthetic spray ready

Other diagnoses to consider 

• Hereditary haemorrhagic telangiectasia 2-4/100 000. Inherited disorder through an autosomally dominant gene. 
• A young male patient with recurrent significant nosebleeds should be investigated for juvenile angiofibroma

Treatment

• Minor bleed: kenacomb ointment 
• Severe bleed --> ED

References:

- General practice by John Murtagh

- RACGP Check program ENT 2011 Case 5

Acute otitis externa

Condition

• Acute otitis externa

Definition 

• infection of the ear canal
• Common responsible organisms
• Bacteria
• Pseudomonas sp. 
• Escherichia coli
• S. aureus
• Proteus sp. 
• Klebsiella sp. 
• Fungi
• Candida albicans
• Aspergillus sp. 

Clinical features 

• Itching at first
• Pain (mild to intense)
• Fullness in ear canal
• Scant discharge
• Hearing loss

Signs

• Oedema 
• Tenderness on moving auricle or jaw
• Erythema 
• Discharge (offensive if coliform)
• Pale cream 'wet blotting paper' debris - C. albicans
• Black spores of aspergillum nigra 
• TM granular or dull red 

Management

• Keep ear canal as dry as possible 
• Remove discharge from the ear canal by aural toilet 6 hourly
• use sofradex or kenacomb 2-3 drops tads 
• pump the triages ( by pressing on it repeatedly without causing pain) for 30 seconds after instilling ear drops 
• Systemic antibiotic offers no benefits unless there are systemic symptoms
• Keep the ear dry during, and for 2 weeks after, treatment

Reference

• eTG
• John Murtagh's general practice 5th edition 

Cholesteatoma

Condition

• cholesteatoma

Definition 

• a sac of keratinising squamous epithelium that arises from a perforation involving the periphery of the TM 
• it is dangerous to the ear because it tends to expand and destroy adjacent structures, including the TM, ossicular chain and cochlear

Diagnosis 

• By recognising " the unsafe ear " / attic perforation on the tympanic membrane 

Treatment

• surgical removal is necessary

Reference

• John Murtagh's General practice 5th edition 

Chronic suppurative otitis media

Condition

• Chronic suppurative otitis media 

Definition 

• is an infection of the middle ear with a perforated eardrum and discharge for at least 6 weeks 

Treatment

• Ciprofloxacin 0.3% ear drops 5 drops instilled into the affected ear, 12 hourly until the middle ear has been free of discharge for at least 3 days
• If a recent perforation (i.e. within the last 6 weeks) caused ear discharge, treat with both oral antibiotic therapy and topical antibiotic therapy. Inadequate evidence for topical corticosteroids

Reference 

• eTG

Acute Otitis Media

Condition

• Acute Otitis Media 

Definition 

• Middle ear infection 
• The common organisms are viral (25%), streptococcus pneumonia, Haemophilus influenza and Moraxella catarrhalis 

Main features

• Fever, irritability, otalgia and otorrhoea 
• TM: translucency, colour, position and motility
• self-limiting (60% of children treated with placebo became pain-free in 24 hours, and spontaneous resolution AOM occurs in approximately 80% of children)
• According to eTG, diagnosis is likely if there is 
• acute onset of signs and symptoms 
• and a demonstrable middle ear effusion (MEE) characterised by any of the following:
• Bulging of the tympanic membrane
• Limited or absent movement of the tympanic membrane in response to changes in air pressure from a pneumatic otoscope
• An air-fluid level behind the tympanic membrane
• Perforation of the tympanic membrane with otorrhoea 
• Signs and symptoms of middle ear inflammation, characterised by redness of the tympanic membrane
• The incidence of mastoiditis in children with untreated AOM is 1: 1000

Management

• Avoid the routine use of antibiotic therapy for acute otitis media
• Initial antibiotic for all children with systemic features and may be required in children younger than 6 months without systemic features. The treatment recommendations apply regardless whether the tympanic membrane has perforated
• Children without systemic features
• In children aged 6 months or older --> observe, if symptoms persist more than 48 hrs, consider antibiotic treatment
• In children aged younger than 6 months --> treat with antibiotic
• Children with systemic features
• amoxycillin 15 mg/kg up to 500 mg orally, 8 hourly for 5 days
• or (for patients suspected to be non adherent) amoxycillin 30 mg/kg to 1 g orally, 12 hourly for 5 days
• Patients who have an inadequate response to amoxycillin therapy within 48 to 72 hours may have infection caused by a beta-lactamase- producing strain of H. influenza or M. catarrhalis, adding clavulanate provides increased cavity against these pathogens. Use
• Amoxycillin + clavulanate 22.5 + 3.2 mg/kg up to 500 + 125 mg orally, 8 hourly for 5 to 7 days
• For patients hypersensitive to penicillins use 
• cefuroxime (child 3 months to 2 years: 10mg/kg up to 125mg; 2 years or older: 15mg/kg up to 500 mg) orally, 12 hourly for 5 days
• trimethoprim + sulfamethoxazole (child 1 month or older) 4 + 20 mg/kg up to 160 + 800 mg orally, 12 hourly for 5 days 

References

• eTG

Approach to deafness and hearing loss

Key points:

- Deafness may be conductive, sensorineural or a combination of both (mixed).

- deafness occurs at all ages but is more common in the elderly. Fifty per cent of people over 80 years have deafness severe enough to be helped by a hearing aid.

- The threshold o normal hearing is from 0 to 20 decibels, about the loudness of a soft whisper.

- One in seven of the adult population suffers from some degree of significant hearing impairment

- One child in every 1000 is born with a significant hearing loss

- Degrees of hearing impairment:
--- mild = loss of 20-40 dB (20 dB is soft-spoken voice)
--- moderate = loss of 40 - 70 dB (40 dB is normal spoken voice)
--- severe = loss of 70-90 dB (shout)
--- profound = loss of over 90 dB

- More women than men have a hearing loss

- People who have worked in a high-noise levels (>85dB) are more than twice as likely to be deaf

- There is a related incidence of tinnitus with deafness

- It is useful to consider the causes of deafness in terms of pathophysiology (conductive or sensorineural hearing loss) and anatomical sites

- Diagnostic strategy model

• Probability diagnosis 
• Impacted cerumen
• Serous otitis media 
• Otitis externa
• Congenital 
• Presbyacusis 
• Serious disorders not to be missed
• Neoplasia
• acoustic neuroma
• temporal lobe tumours (bilateral)
• otic tumours
• Severe infections
• generalised infections (e.g. mumps, measles)
• meningitis
• syphilis
• perforated tympanic membrane
• cholesteatoma
• Perilymphatic fistula 
• Meniere syndrome
• Pitfalls (often missed)
• Foreign body
• Temporal bone fracture
• Otosclerosis
• Barotrauma
• Noise-induced deafness
• Rarities
• paget disease of bone 
• multiple sclerosis 
• osteogenesis imperfecta 

- When to refer 

• sudden deafness
• any child with suspected deafness, including poor speech and learning problems, should be referred to an audiology centre
• Any child with middle-ear pathology and hearing loss should be referred to a specialist
• Unexplained deafness

Reference:

John Murtagh General practice 5th edition 

Acute Otitis Media

Acute Otitis Media 

I see so many ear pain everyday, however, I still feel that I don't have a good grasp on this topic. Parents are often anxious and pushing for antibiotics. I believe that GPs do have a standard to uphold and should only prescribe it only when it is clinically indicated. 

Key Points:

- The diagnosis of AOM is difficult to make especially in children under the age of 3. Studies have shown that the accuracy was: ENT surgeons 74%, paediatricians 51% and GPs 46%.

- Recurrent otitis media is 3 or more episodes in 6 months or 4 or more in 12 months. 

- Common organisms which cause AOM are: streptococcal pneumoniae, Haemophilus influenza-nontypeable and moraxella catarrhalis. 

- Treatment of AOM involves the following:

• Adequate analgesia: paracetamol, amethocaine, benzocaine or lidocaine.
• Antibiotic therapy recommendations:
• well, older than 2 years, no ABx for 48hrs
• Children under the age of 2 as they are more likely to develop complications
• children with severe illness with pain, or a tympanic membrane perforation 
• a child with known immunodeficiency 
• indigenous children, including aboriginal, Torres Strait islander and Maori and other Pacific Islander children
• Children with a cochlear implant
• antibiotic regime: amoxycillin 15mg/kg 3 times per day x 5days; allergic to penicillin, use cefuroxime 10mg/kg to 500 mg twice per day for 5 days or ceflacor 10mg/kg up to 250 mg 3 x per day for 5 days
• topical antibiotics (mainly ciprofloxacin) can be used with tympanic membrane perforation
• Vaccination with the polyvalent pneumococcal vaccine reduces the incidence of am BY 8 % 

- Prevention of recurrent otitis media

• avoid childcare
• avoid smoking 
• breastfeed x 6 months to 12 months
• avoid pacifiers/dummies
• polyvalent pneumococcal vaccines
• 2 weeks after an episode of AOM, 70% of children will have middle ear effusion but most perforation would have healed.
• Treating blocked nose may not help with acute otitis media. Saline to clear the nose and steroid spray to reduce the size of adenoid
• Adenoidectomy has not been shown to be effective in preventing recurrent AOM

References:

- Check program : ENT