FACTS ON FINGER TIPS(MIMS)

 1. EPISTAXIS                                                               

     Salient Features

Definition

1. Nasal bleeding

Epidemiology

1. Relatively common in children and elderly

Aetiology

1. Idiopathic in many cases
2. Bleeding from Little’s  area is common in children and young adults, and is typically triggered by local infection, hot weather or minor trauma
3. Nosepicking is a common cause of frequent, easily controlled nose bleeds in children
4. Other local causes include a tumour, pyrogenic granuloma disorders such as thrombocytopenia or haemophilia
5. Drug induced causes include anticoagulation therapy and intranasal corticosteroids

Examination and investigations

1. Examine the nose to check for local pathology and look for bleeding point
2. Check blood pressure and pulse
3. Investigations are not normally needed, but check the FBC in patients with large recurrent bleeds
4. Check the INR in patients on warfarin

Management

1. Encourage the patient to sit forward to minimise swallowing of blood, and press on the anterior of the nose for 10-15 minutes
2. Advice against swallowing as this may dislodge the clot.
3. Treat the bleeding points with cautery
4. If bleeding cannot be controlled, do nasal packing

Key points

1. In the elderly, bleeding may be so heavy that emergency admission and resuscitation are needed.
2. Hypertensive epistaxis arises from high up in the nose and may be difficult to control

10.DISORDERS AND /OR ADVERSE REACTIONS - EAR, NOSE AND THROAT - SUMMARY

Ref- Other information

Contents

1.Evidence Based Medicines                                                                                                i.Treatment of Aphthous Ulcers

2.Facts on Finger Tips                                                                                                           i.Epistaxis                                                                                                                             ii. Acute Maxillary Sinusitis                                                                                               iii.Peritonsillar Abscess                                                                                                     iv. Otitis Externa                                                                                          

3.Disorders/and/or Adverse Reactions                                                                               Items   1 to 13

                              EVIDENCE BASED MEDICINE (April 2003)

FACTS ON FINGER TIPS (MIMS)

 3. PERITONSILLAR ABSCESS                                                          

     Salient Features

Definition

1. Peritonsillar abscess or quinsy is the most common complication of acute tonsillitis
2. It represents abscess formation in the space between the tonsil and the lower tonsillar bed

Presentation

1. Starts with acute tonsillitis with sore throat, pain on swallowing and fever
2. The patient becomes increasingly unwell. Severe dysphagia may prevent swallowing
3. The patient will typically have a hot ‘potato’ voice and trismus.
4. Inspection of oropharynx is required to make the diagnosis, by gentle tongue depression with a spatula.
5. There will be obvious swelling around the tonsil with medical displacement of the tonsil.
6. Quinsy manly occurs in young adults and is rare in children and elderly

Treatment

1. A quinsy will require drainage to speed resolution and reduce other complications such as neck abscess formation
2. Drainage may be achieved by needle aspiration or incision after spraying with local anaesthetic
3. Patients are usually admitted and given intravenous antibiotics, fluids and analgesia following drainage

Key Points

1. A single episode of quinsy is not usually considered an indication for tonsillectomy
2. A patient with a history of recurrent tonsillitis with quinsy or recurrent quinsy would be offered elective surgery
3. Recurrence of quinsy occurs in up to 23 percent of patients, with a further 20 percent going to suffer recurrent tonsillitis

FACTS ON FINGER TIPS (MIMS)

  4. OTITIS EXTERNA                                                   

     Salient Features

Definition

 1.   Infection and inflammation of the skin lining the external auditory meatus

Pathology

1. Commonly caused by bacterial or fungal infection.
2. May be localised (furunculosis) or diffuse
3. It is five times more common in swimmers
4. Other risk factors include having a narrow or tortuous external canal, and humid environments
5. Underlying skin diseases such as eczema or psoriasis may be responsible for intractable infections

Clinical features

1. Pain may be severe, and is often increased on moving the pinna
2. Discharge
3. Deafness
4. The ear canal contains moist debris with an offensive smell, and oedematous meatal walls. The tympanic membrane may be obscured with the debris
5. The post-auricular lymph node may be tender

Differential diagnosis

1. Foreign body, especially in children
2. Ramsay Hunt Syndrome

Management

1. In severe cases, ENT referral for aural toilet to remove infected debris
2. Pain killers if pain is severe
3. For mild cases, antibiotic ear drops, often combined with a steroid to reduce inflammation
4. Treat any underlying skin conditions

Key Points

1. In refractory cases, exclude the possibility of otitis media with a perforated, discharging tympanic membrane
2. Steps to prevent re-infection are important and include not cleaning ears with cotton buds and wearing a hat that covers ears when swimming

10.DISORDERS AND /OR ADVERSE REACTIONS -  EAR,NOSE AND THROAT -SUMMARY

( Ref- Harrisons - Priniciples of Internal Medicine Ninth Edition )

1. Vestibular disorders  ( 388 )
2. Deafness ( 108 )
3. Anosma (1254)
4. Rhinophyma (1254)
5. Rhinitis and Nasal Obstruction (1254)
6. Perforation of the nasal septum (1255)
7.Epistaxis (1255)
8.Nasal Furnunculosis (1255)
9. Nasal tumors (1255)
10. Acute Pharyngitis (1255)
11. Perionsillar cellulitis and abcess (Quincy) (1256)
12. Paraphayngeal space abcess (1256)
13. Retropharyngeal Abcess (1256)

1. Vestibular disorders  ( 388 )

   Adverse reaction - drug
     1. Aminoglycosides
     2. Quinine
     3. Mustine

2. Deafness ( 108 )

Tinnitus and deafness are frequent symptoms and always indicate disease of the  ear or of the auditory nerve and its central connections . Tintus or ringing in the ears is purely subjective phenomenon and may be reported as buzzing, whistling, hissing, or roaring sound. It is a very common symptoms in adults.

  Adverse reaction - drug ( 388 )
    1. Aminoglycosides
    2. Ethacrynic acid
    3. Furosemide
    4. Quinine
    5. Bleomycin
    6. Chloroquine
    7. Mustine
    8. Aspirin
    9. Nortriptyline

3. Anosma (1254)

Total loss of olfactory sense is most common as a transcient manifestation of the upper respiratory tract. It may be present with chronic nasal obstruction due to edema of the mucosa or marked swelling of the turbinates and congenital defects, ozena, tumors, trauma involving the olfactory nerves and nasal polyps.

4. Rhinophyma (1254)

This is a progressive, deforming, nodular enlargement of the alae nasi due to hypertrophy of
sebaceous follicles in association with chronic acute rosacea. There is no specific treatment. Plastic surgery may produce  dramatic degree of improvement.

5. Rhinitis and Nasal Obstruction (1254)

Intermittant or persistent nasal discharge may be caused by a variety of disorders, including
hay fever, vasomotor rhinitis and complicating nasal ployposis, acute coryza, and other forms of viral rhinitis, the upper respiratory manifestations of measles, syphilis ( the snuffles of the congenital disease) and nasal diphtheria , intranasal foreign bodies, and chronic use of vasoconstrictor drugs.

Acute and self-limited nasal obstruction usually associated with acute upper respiratory tract infections, most commonly viral.

6. Perforation of the nasal septum (1255)

A variety of conditions may cause perforation of the nasal spectum, including chronic nose -picking- prolonged use of potent vasoconstrictors, chronic sniffing of cocaine, cautery of the nasal spectum for reported episodes of epitaxis, tumors of the nose invading the septum, nasal septal surgery,rheumatoid arthiritis, syphilis.

7.Epistaxis (1255)

Probably the comonest cause of is nose picking leading to tearing of the rich network of veins in the anterior nares. Among the infections in which acute nosebleed may develop are typhoid fever, unilateral nasal diphtheria, pertussis and malaria. Minor epistaxis may also appear in the course of viral infections of the upper respiratory tract. 

8.Nasal Furnunculosis (1255)

Furuncles involving the internal or external surfaces of the nose pose potential threats to life
because of the possibility of spread to the cavernous sinus via the draining veins. When seen in the early stage, they respond rapidly to antimicrobial therapy which be directed primarily against staphylococcus aureus and given large doses.

Oral treatment may be adequate in the early stages of the disease, but parentral therapy is
necessary when the constitutional reaction is severe and there is a marked edema of the
intra-or extranasal tissues.

Under no circumstances should these lesions be squeezed because of the danger of spread of organisms to the intracranial venous sinuses.

9. Nasal tumors (1255)

Basal cell carcinoma of the skin covering the nose is the commonest tumor of this organ.
Rodent ulcer resulting from local spread of a basal cell lesion may involve not only the skin
over the external nasal surface and adjacent areas of the face over the extrenal nasal surface and adjacent areas of the face, but may also invade intranasally and produce marked destruction of the internal structures

10. Acute Pharyngitis (1255)

The oustanding symptom of acute pharyngitis , regardless of the cause,is a sore throat. About two-thirds of all acute illness in families are viral infections of the upper respiratory tract, with varying degrees of pharyngeal discomfort present. The acute pharyngitides can be classified into three groups - 1. treatable infections 2. untreatable infections and                 3. noninfectious disorders

The tonsils are often involved in the course of viral and bactetial pharyngitis, they may be markedly reddened and swollen and contain exudate in the crypts.

11. Perionsillar cellulitis and abcess (Quincy) (1256)

This condition is most often a complication of acute pharyngitis. The organism commonly involved are group A S pyogenes and S aureus.  The first sign of this disease is marked enlargement of the tonsils, which are surrounded by red,edematous pillars. The tonsillar and peritonsillar  hypertrophy may progress to a degree threatening occlusion of the upper airway. High grade fever and leukocytosis are present and severe rigors may occur.

In its early stages the process is cellulitis, but in the absence of therapy, abcess develops as infection progresses and invlolves one or both tonsils, at this time ,soft grayish white  exudate may cover the tonsillar surfaces. 

12. Paraphayngeal space abcess (1256)

This syndrome is always a complication of acute pharyngitis. primary or secondary bacterial
invasion of one of the tonsils results in the development of  an intratonsillar abcess accompanied by considerable edema and inflammatory reaction in the parapharyngeal space.

The lesion is usually unilateral , there is very little pharyngeal discomfort, but there is a marked tenderness at the angle of the jaw on the same side of the tonsillar abcess. The reminder of the throat has a benign appearance.

13. Retropharyngeal Abcess (1256)

Infection of the retrophargeal lymph nodes occur most often as a complication of acute bacterial pharyngitis in children 3 years  of age or younger, these nodes disppear rapidly  after this age. Adults usually acquire the disease as a result of injury of the posterior phrygeal wall by a sharp object, as complication of negleted acute infection of the middle ear, during the course of tuberculosis or secondary to supparative parotitis.

 A universal symptom to the sensation of a - lump in the throat  that cannot be swallowed-.
 Dyspnea that is present in the sitting position and absent when patients lie in their back and
pain on swallowing are common.