Rhinosinusitis 556 The 2007 European Position Statement (EP3OS) de \201 nes rhinosinusitis (includ- ing nasal polyps, p557) as in \202 ammation in the nose and paranasal sinuses with \211 2 symptoms , one of which must be nasal congestion or nasal discharge. Oth- er symptoms of rhinosinusi tis: facial pain or pressure, \200\201 olfaction; endoscopic signs of nasal polyps or mucu s pus discharged primarily from the sinuses, or CT showing mucosal changes within the si nuses. Rhinosinusitis symptoms are diagnosed as mild, moderate or severe \200\224and as acu te (ARS) or chronic (CRS, if lasting >12wks). \201 : Topical corticosteroids and oral anti biotics, are 1st line for adults with ARS. For adults with CRS with or without nasal polyps , EP3OS recommends that primary care physicians and non-ENT specialists prescribe topical s teroids and nasal douching (p560) as 1st-line therapy. Other causes of nasal congestion Chi ld: Big adenoids, rhinitis, choanal atre- sia, postnasal space tumor (eg angio \201 broma) , foreign body ( \200\207refer same day if unilateral obstruction foul/bloody discharge) . Adult: De \202 ected na- sal septum, granuloma (TB, syphilis, granulomatosis with polyan giitis, leprosy), topical vasoconstrictors, tricyclics. \200\207Refer urgently if: \200 Numbness \200 Tooth loss \200 Bleeding \200 Unilateral obstructing mass \200 Tumor may be present. Ask: do symptoms vary? Is it both sides? Any eff ects on eating, speech, sm ell, or sleep (snoring)? Assess nasal de \202 ection. Is either nostril completely blocked (does a mirror held under each nostril steam up)? Examine the post- nasal space (scope or mirror). Allergic rhinosinusitis may be seasonal (hay fever, prevalence \211\2102%, high r isk at 5 \200\22314yrs old) or perennial. Cause: IgE-mediatied in \202 ammation from aller gen exposure to nasal mucosa causing in \202 ammatory mediator release from mast cells, eg from house dust mite (perennial) or pollen. Symptoms: Sneezing; pruritus; rhinorrhoea (bil ateral & variable). Signs: Turbinates may be swollen and mucosae pale or mauve; nasal polyp s. Skin tests may show al- lergens (avoid if prone to eczema, allergies, dermatographism, o r on interfer- ing antihistamines or steroids). Here, consider radio-allergosorbent (RAST) tests to \201 nd speci \201 c IgE. \201 : Antihistamines: Loratadine.1 Systemic decon- gestants (pseudoephedrine 60mg/6h PO; CI: BP \200\200 , hyperthyroidism, heart dis- ease, M AOI use), nasal sprays (eg sodium cromoglicate 2%, 1 spray/4 \200\2236h), or nasal steroids , eg beclometasone 4 \200\2238 \211\210 50 g puff s/24h. Steroid puff ers may be used ind e \201 nitely, but steroid drops are systemically absorbed: use for <1 month at a time, <6 times/yr. Oral steroids or stat depot triamcinolone 40 \200\223100mg IM (buttock) may help the bad times. Immunotherapy: 2 \200\207When rhinitis coexists with asthma (it does in up to 60%) a nasal steroid + an anti- leukotriene agent (za \201 rlukast 20mg/12h PO, adults only) may be better than loratadine/pseudoephedrine.115,116 It may stop rhinitis triggerin g asthma. Other causes of chronic rhinorrhoea/rhinitis Allergies, foreign body, CSF (eg aft er head injury; +ve for glucose), bacteria (eg TB), HIV, cystic \201 bro- sis, Kartagener \200\231s syndrome, rheumatoid arthritis, atrophic, age (old man \200\231s drip3), pregnan cy, the Pill, \200 -blockers, NSAIDs, decongestant overuse, anti- body de \201 ciency (p1 98), non-allergic rhinitis with eosinophilia (NARES). s e s a e s i d T N E 1 Cetirizine, desloratadine, fexofenadine & mizolastine are all similar at a one-tablet-a-d ay dose and choice may be according to patient preference, availability, interactions, and price. Typically, antihista- mines interact eg with erythromycin and other macrolides, grap efruit, \202 uoxetine, and systemic ketocon- azole, but these eff ects are not seen with desloratadine (nor is antihistamine-associated \200\200QT interval).117 2 Once-daily subli ngual immunotherapy (SLIT) improves quality of life in grass-pollen-induced rhinosinusi- ti s, eg once-daily grass allergen tablets (2,500; 25,000; or 75,000 SQ-T phleum pratense extr act as Grazax ); start \211 4 months before the pollen season; continue for up to 3yrs.11 8 Injection immunotherapy involves an induction course of the speci \201 c allergen. \200 \207SE: anaphylaxis (esp. if asthma too), so administration should be under monitoring, wit h adrenaline and resus. equipment to hand. Bene \201 cial eff ects can last for years. 119 The future for some patients may lie in same-season ultra-short course allergy vaccine (eg 4 injections N =1028. SE: itch at injection site of Pollinex Quattro using natural allergens modi \201 ed to enable higher doses).120 (ri sk of anaphylaxis not yet quanti \201 able, but there were no serious incidents in the abo ve trial). 3 Old man \200\231s drip often occurs on eating, and ipratropium nasal spray (Ri natec ) may help.121 557 Nasal polyps Typical patient: \200 >40 years old. Histology: Ciliated columnar epi- theli um with a thickened basement membrane and an avascular oedem- atous stroma. 90% are eosinop hilic.122 Sites: Middle turbinates; middle meatus; ethmoids. Single, benign maxillary polyp s may arise in the maxillary antrum, and prolapse to \201 ll the nasopharynx (antrochoana l pol- yps). \200\207A polyp causing unilateral na- sal obstruction may be sinister: refer promptly (esp. if pain or bleeding). Symptoms: Watery anterior rhinorrhoea, purulent postn asal drip, nasal ob- struction, change in voice, anosmia/taste disturbance, sinusitis, head aches, mouth-breathing, snoring, mucocele (presents with a lump on the medial su- perior bo rder of the orbit); pain (uncommon; eg over the dorsum of the nose). Signs: It can be hard to distinguish hypertrophied inferior turbinates from pol- yps, but if a polyp, it is pale, mobile, and insensitive to gentle palpation. Drugs: 1% betamethasone, 1 drop/8h for 48h (l onger courses may be safe). \200\207Nose drop pos- ture: ( \201 g 2) simply tilting the h ead back doesn \200\231t work!123 Bend double at hips, with nostrils point- ing at the sky (Mygind position), or kneeling with the vertex/forehead on the \202 oor (praying- to-Mecc a). This may make polyps quickly diminish, and maintenance with beclometasone spray may the n be tried, eg 8 puff s/24h (50 g/puff ). 1 \200\2232wks of oral prednisolone may give sho rt- term benefit, but the evidence is limited to poor trials,124 eg at the high dose of 50m g/day for 2wks.125 Balance bene \201 t against risk (OHCM p361).122 Anti-leukotrienes (p16 4) and continuous low-dose clarithro- mycin (250mg/24h for 2wks then 250mg/24h PO) are also used. Endoscopic polypectomy: If more than simple polypectomy is planned, do CT to show an atomical variations. Complications of endoscopic surgery are rare, but can include damage t o the optic nerve and CSF leak (OPPOSITE). Post-op: \200 \200\234Don \200\231t blow your nose until you are better \200\235 \200 Watch for bleeding \200 Abide by epistaxis advi ce (p562) \200 Topi- cal steroids, eg beclometasone drops/12h (days 2 to 30) \200 0.9% saline douched or sniff ed from the palm to relieve crusting. Children \200\207Nasal polyp s are rare if <10yrs old; rule out neoplasms, cystic \201 bro- sis, and meningocele/encep halocele (esp. if unilateral and <2yrs old). A single unilateral \200\230polyp \200\231 epistaxis may turn out to be a sign of rare but serious intranasal pathology (eg nasophary ngeal cancer, glioma, lymphoma, neuroblastoma, or sarcoma).138 Do prompt CT and get histolo gy. Prevalence: 2%. s e s a e s i d T N E Fig 1. Polyp arising from right middle mea- tus. NB: the lower part of septum deviates R Herdman frcs to this side. Polyps associate with: \200 Allergic rhinitis \200 Non-allergic rhinitis \200 Chronic ethmoid sinusitis Cystic \201 brosis \200 Aspirin hypersensitivity \200 Asthma (eg non-atopic) Fig 2. How to use nose drops \200\224left two images; both the methods on the right are equ ally useless. The paranasal sinuses These are air- \201 lled cavities in the bones around the nose, in c ontinuity with the nasal cavity ( \201 g 1). They are lined by ciliated mucosa; debris and mucus are swept towards and through ostia into the nostrils ( \201 g 2). Viruses cause mu c osal oedema and \200\201cilia action, hence mucus retention and secondarily bac- terial infection. Polyps/septal deviation \200\203poor drainage \200\203sinusitis. Current em- pha sis concentrates on recognizing and correcting these drainage problems. Sinusitis divides ( imprecisely) into acute or chronic or recurrent: Symptoms: \200 Pain: maxillary (cheek; t eeth) or ethmoidal (between eyes), worse on bending. \200 Discharge from nose, eg postnas al drip causing a foul taste in the mouth. \200 Nasal obstruction/congestion. \200 Anos mia: \200\201smell; cacosmia (bad smell sensation without external source). \200 Systemi c symptoms, eg fever. \200\207Swelling is uncommon: exclude carcinoma or dental root infec tions. Diff erential diagnosis of sinusitis (non-sinus pain): migraine, TMJ dysfunc- tion ( p542), neuralgias, cervical spine disease, temporal arteritis, herpes zoster. Causes of bac terial sinusitis (BS) Most follow viral infection. 4 others: 1 Direct spread (dental root i nfection or diving/swimming in infected water). 2 Odd anatomy: septal deviation, large ethm oidal bulla, polyps, large uncinate process (the part of ethmoid bone forming the maxillary sinus medial wall). 3 ITU causes: mechanical ventilation, recumbency, use of nasogastric t ubes. 126 4 Systemic causes: Kartagener \200\231s, immunode \201 ciency, or general debili ty. 5 Bio \201 lms1 denude mucosal cells of cilia and goblet cells. \200 : A catheter att ached to a syringe is as good as the \200\230suction trap \200\231 nasal colle- ctor.127 B oth may miss organisms growing within bio \201 lms or in mucosal cells. 128 Frequent bacte ria: S. aureus, Pseudomonas aeruginosa, S. pneumoniae, H. in- \202 uenzae, and Moraxella catarrhalis. Fungi.2 Tests (None is usually needed.) ESR \200\200 & CRP \200\200 may be mor e reliable for BS than CT.129 Endoscopy + CT is a sensitive method and helps plan surgery, identify un- derlying problems (anatomical pitfalls, eg low cribiform plates or vulnerable carotid arteries). Plain radiographs (occipitomental, occipitofrontal, and later- al views typically) and ultrasound are of little use. Normal radiographs cannot exclude sinus diseas e and 30% of normal sinuses show mucosal thickening.130,131 Treatment Acute/single episode: Most are self-limiting. After 5 days of symp- toms, nasal douching (p560) and topical ster oids/decongestants can be con- sidered. Antihistamines are not routinely used as they may t hicken secretions (eg amoxicillin or co-amoxiclav). 132 N=214 and complicate drainage. Anti biotics may prevent complications. Chronic/recurrent episodes: (eg S. aureus or an- aerobes .) 133 If antibiotics fail refer for FESS (functional endoscopic sinus surgery) tailored to the particular sinus aff ected. 134 High-volume, low-pressure rinsing of the surgical cavi ty can aid healing. Suction cleaning may be tried weekly start- ing 1wk post-op (continue u ntil secretions, blood, and crusts disappear). Flutic- asone nasal spray 200 g/12h startin g 6 weeks post-op may have long-term ad- vantages (fewer rescue courses of prednisolone & a ntibiotics needed at 5yrs). 135 Smoking cessation helps as tobacco irritates nasal mucosa a nd \200\201cilia function. 136 Complications Less common than previously (?from better hea lth anti- biotic use). Mucocoeles (esp. frontal sinus) may become infected pyocoeles. Or bital cellulitis/abscess (this is an emergency, p420). Osteomyelitis (classi- cally staph, eg frontal bone). Pott \200\231s puffy tumor (subperiosteal abscess).137 Intracranial infec tion: (Conscious level \200\201; cerebral irritability) Meningitis, en- cephalitis, cerebra l abscess, cavernous sinus thrombosis. 558 s e s a e s i d T N E 1 A bio \201 lm is an aggregate or micro-organisms on a living or inert surface. 2 Aspergi llus (63%) candida, mucor.138 2 types: invasive or allergic, eg triggering asthma. \200 : culture; \200 -D- glucan \200\200; histology; \201\227: (if invasive) antifungals+endonas al debridement;139 HIV (may coexist; also diabetes or steroid use). 559 Why do we have paranasal sinuses? No one knows s e s a e s i d T N E Fig 1. Sinus anatomy. Redrawn with permission from Medtronic Perhaps these pneumatic cavities are there to reduce the weight of our skull, Galen thought (but a pair of spectacles more than compensates) or maybe they moisten and warm the air as it goes to our lungs? Does their unique shape gives our voice its own timbre, so useful in recognizing each other when on diff erent supermarket aisles? No! \200\224according to stu dies of pitch, dynamic range, sound pressure, jitter, shimmer and noise-to- harmonics ratio . 140 But they do make nitric oxide and aid immune defenses. 141 Sinuses develop before (ma xillary then ethmoid) and after birth (sphe- noid then frontal) from invaginations in the n asal cavity that develop into the bones, so they contribute signi \201 cantly to the growt h of the facial bones \200\224another connection of sinus function with personal identity. The maxillary sinus is particularly susceptible to congestion and subse- quent infection, b ecause its most dependent part lies below the level of the ostium (when standing), and so f ree drainage is impossible in this position. Fig 2. The nasal conchae and meati. The table below shows the patterns of drainage of the sinuses & nasolacrimal duct. Sinus Meatus Middl e Maxillary Anterior ethmoidal Middle Middle ethmoidal Middle Posterior ethmoidal Superior Spheno- Sphenoid ethmoidal recess Middle Inferior Frontal sinus Superior concha Superior meatus Sphenoethmoidal sinus Sphenoid sinus Middle concha Middle meatus Inferior concha Inferior meatus Frontal Nasolacrimal duct Nasal injury and foreign bodies Undisplaced nasal fractures may need no treatment. If displ aced, reduction (under GA) with post-op splintage is best within 2wks (complete setting occ urs at 3wks). Advise to apply ice for the 1st 12h post-op; sleep with head elevated, sneeze through mouth, don \200\231t blow the nose or do vigorous exercise. Septal de- viation may need septoplasty later. Post-traumatic nasal deformity is common (14 \200\22350%); this is reducible to 9% by complete nasal assessment (bony and sep- tum), and primary septal recon struction if severe septal fracture-dislocation. 142 CSF rhinorrhoea Ethmoid fractures disr upting dura and arachnoid can re- sult in CSF leaks. \200\207If not associated with trauma , ask: is it a tumor? Nasal discharge tests +ve for glucose (Clinistix test \200\224unrel iable, so con \201 rm with a lab glucose); CSF uniquely contains \200 2 (tau) transferrin , tested for with im- munoelectrophoresis (needs >0.5mL; the gold standard).143 Conservativ e man- agement: a lumbar drain and bedrest. Surgery is often not needed. Traumatic leaks sh ould be covered with antibiotics and Pneumovax . Foreign bodies Most are self-inserted by children. Organic material presents early with purulent discharge; inorganic bodies may rem ain inert for ages. If a child is co-operative it may be possible to grab the object with f orceps or a hooked instrument. An understanding parent/child team with good head immobiliza tion (eg held between the parent \200\231s legs, wrapped in a blanket to stop wriggling) ca n make for successful removal. 2.5% cocaine spray (avoid in children) may shrink the mucosa and allow extraction with a sucker. Foley catheters can also be useful. Batteries need urg ent removal. If GA needed, protect the airway.144 A \200\230parental kiss \200\231 has bee n described with +ve pressure behind the object by blowing into the mouth whilst occluding the other nostril. Causes of septal perforation After septal surgery (p561); trauma; nose p ick- ing; body piercings; nasal prongs (O2 delivery); sniffi ng chrome salts or cocaine; ma lignancies (eg rodent ulcer); nasal steroid/decongestant sprays, 145 any chronic mucosal in \202 ammation/granuloma \200\224eg TB; syphilis; HIV, extra-GI Crohn \200\231s;146 sar- c oidosis; SLE; granulomatosis with polyangiitis; relapsing polychondritis (chondritis in aur icles, nose and trachea non-erosive polyarthritis, eye in \202 ammation, and ves- tibul ar or cochlear damage; it may be fatal).147 Perforations irritate, whistle, crust, and blee d. \201\227: Symptomatic. Closure is hard (may be done with rhinoplasty; a one- stage proc edure). 148 Saline douche for crusts;1 silastic buttons to occlude the hole. 560 \200 s e s a e s i d T N E Septal haematoma 6 \200\223 Vomer 1 \200\223 Quadrangular cartilage Septal deviation Perichondrium 5 \200\223 Anterior septal angle 4 \200\223 Middle septal angle 7 \200\223 Perpendicular plate of ethmoid bone 3 \200\223 Posterior septal angle 9 \200\223 Maxillary crest \200\223 palatine component 2 \200\223 Nasal spine 8 \200\223 Maxillary crest \200\223 maxillary component Fig 1. Is surgery needed for this case of septal deviation? Maybe, but you cannot rely on o bjective tests such as rhinomanometry.149 Endoscopic repair may be superior to open procedu res.150 The main issues in nasal surgery are to stabilize the nose in the good posi- tion a fter surgery and preserve the cartilages and bones in the favorable situation and reduce th e risk of deviation recurrence. Also it is necessary to avoid synechia formation, nasal val ve narrowing, haematoma, and bleeding. Septoplasty can be safely performed without post-op nasal packing (may have complications such as pain, sleep problems and even toxic shock).15 1 561 Septoplasty, septorhinoplasty Septoplasty corrects a deviated nasal septum. Septorhinoplast y aims to straighten and or refashion the shape of the nose too for cosmesis and to help br eathing by improving the airway. For an operative description of and pre-op assessment, see www.noseandsinus.com/BeckerSeptoplastyPaper.pdf Complications: Bleeding (repacking may be needed); CSF leakage (nurse semi- upright; avoid blowing the nose; \202 ap surgery may be needed); altered sensa- tion of lips, gums and incisors. If a septal haematoma develops, d rain and give IV antibiotics to prevent a septal abscess (formal drainage may be needed, an d may not prevent septal perforation). Adhesions between the septum and the lateral nasal w all may need division. s e s a e s i d T N E 1 Put 1 teaspoonful of salt in \211 500mL tap water (distilled if quality poor) and sniff the liquid from a cupped hand. A unilateral squirt from a 10mL syringe (or an old Beconase container) is an alternative. Adding 1 teaspoonful of baking soda (sodium bicarbonate) im proves the mucus-solvent properties of the irrigant.152 \200 Nosebleed (epistaxis): the chief ENT emergency Respect all nosebleeds; they can be fa tal. They are anterior or posterior ; an- terior bleeds that can be easily seen with rhinos copy are simpler to treat and are usually less severe. Proceed as follows: G-up (gown, gogg les, gloves), then: \200 Resuscitate as needed, eg if BP \200\201 or dizzy on sitting up. ABCs; IVI, SAO2, etc. Monitor vital signs often. \200 History: Which side? Trauma? How muc h loss? On warfarin/aspirin? Note past medical history. \200 Ask him to apply pressure by pinching the lower part of nose for 15min while mouth-breathing and sitting forward so bloo d can be spat into a bowl. \200 Fully decongest (eg with ephedrine 0.5% drops). \200 Plac e ice pack on the dorsum of the nose (ice may also be sucked). If this doesn \200\231t stop the bleed \200 Prepare silver nitrate cautery. Ask a nurse to help. \200 Encourage th e patient to blow out nasal clots. \200 Look in side (headlamp+speculum); remove clots (ge ntle suction; spray on lidocaine and pheny l- ephrine (vasoconstrictor); wait a few minutes . \200 Find bleeding points (eg indicated by prominent surface clot, often on the anterior septum. Apply cautery for 10sec. Start from the edge of the bleeding point and move in on a radius. Remember: \200\234silver nitrate cauterizes everything it touches. \200\235 Kee p it away from alae nasae. Get support to keep your hand steady. Never cauterize both sides of the septum (risks perforation). 153 \200 If you cannot see the bleeding point, refer t o ENT.154 \200 If bleeding continues, try an anterior nasal pack (paraffi n gauze; Merocel ). Lub ricate the pack (KY ); advance it all the way into the nose (direc- tion is horiz ontal, not up). If all is well, remove af- ter 24h. If bleeding continues, try a postnasal pack (Foley catheter, 16-18G \201 lled with >10mL water);1 get help from a colleague. Adm it patients with packs and use the history to plan searches for a cause. If there is no mor e active bleeding, the pa- tient may be discharged with an advice lea \202 et providing th ere are no other medical problems. 562 \200 Fig 1. Vessels in Little \200\231s area (left side of septum; \201 g 2 for anatomy). Thes e are the main cause of epistaxis in children. Rory Herdman Causes/associations \200 Trauma (local/facial) \200 Local trauma or infection \200 Hy pertension 155 \200 Dyscrasia/haemophiliaet al \200 Alcohol intake \200\200 \200 Sept al perforation \200 Neoplasm After the bleed \200 Don \200\231t pick your nose! \200 Sit upright, out of the sun \200 Avoid bending, lifting, or straining on the toilet \200 If you sneeze, send it thr- ough your open mouth s e s a e s i d T N E No hot food or drink \200 Avoid alcohol/tobacco \200 If it restarts, apply ice to the b ridge of the nose, and hold the soft lower part continuously for 20 min; get help if this f ails. Anterior epistaxis is almost invariably septal; Little \200\231s area (Kiesselbach \200\231 s plex- us) is used to describe this area where anterior ethmoidal, sphenopalatine, and fac ial arteries anastomose to form an anterior anastomotic arcade ( \201 gs 1 \200\2232). Ser ious posterior epistaxis More invasive procedures (see 2) may be best: 1 Examination under anesthesia: If a discrete bleeding point is found it can be treated directly, eg with diath ermy, otherwise repacking may be needed. Correction of septal deviation may improve access. 2 Ligation: The emerging gold standard is endoscopic ligation of the maxil- lary/sphenopala tine artery around the sphenopalatine foramen. 156,157 This is preferred to transantral art erial ligation of maxillary artery or ligation of the anterior ethmoidal artery. Sometimes ligating 2 arteries is necessary (eg the contralateral one).155 \200 Embolization can be l ifesaving eg for bleed- ing not responding to surgical measures \200\224but this can cause stroke. 1 An alternative is the Brighton device with anterior and posterior balloons: they are more expensive and inhalation of clot has been reported.158 563 1 2 4 5 3 6 s e s a e s i d T N E 7 Fig 2. 1 Anterior ethmoidal artery (a.) 2 Posterior ethmoidal a. 3 Sphenopalatine a. ( \211 2 branches, as on the dissection). 4 Little \200\231s area (anterior ethmoidal, sphenopala tine, and facial arteries anastomose to form this anterior anastomotic arcade) 5 Septal bra nch 6 Greater palatine a. 7 Superior labial a. and branches (from facial artery). Courtesy of Prof Tor Chiu who performed the dissection. The tonsils \200\224sore throats, and beyond 564 \200 Tonsillitis (sore throat lymphadenopathy, especially jugulodigastric) often caused by Group A streps (eg Streptococcus pyogenes). Other pathogens include: staphs, Mora xella catarrhalis, mycoplasma, chlamydia, haemophilus. See \201 g 1. Tests: Swabbing supe r \201 cial bacteria in suspected cases is irrelevant and can lead to overdiagnosis. \201 \227: Paracetamol Diffl am gargle if severe; antibiot- ics are unlikely to help (BOX 1 ) as most are viral, but if ill or (Centor citeria +ve): 1 penicillin, 250mg/6h usually PO (125mg/5mL, 5mL/6h PO if <6yrs; eryth- romycin if penicillin allergic) for 5 days; not amox i- cllin (bad rash in almost all whose pharyngitis is from EBV). Consider alternating parac etamol/ibu- profen (both are antipyretic and analgesic). Complications of tonsillitis Ask y ourself: is he immunosuppressed? \200 Retropharyngeal abscess: This is rare; typical pati ent: ill child with a stiff , extended neck/tor- ticollis who fails to eat or drink. Latera l neck X- ray: soft tissue swelling. \201\227: Incise and drain pus under GA (head-down, t o prevent aspiration). Diff erential diagnosis: \200 Epstein \200\223Barr virus \200 Agranulocytosis \200 Le ukemia \200 Scarlet fever; diphtheria Fig 1. Tonsillitis in a child (ery - thema, follicle pus + narrow airway). Think of Kawasak i disease (p646) if peeling skin or platelets \200\201 Rory Herdman s e s a e s i d T N E Peritonsillar abscess (quinsy) presents with sore throat, dysphagia, peri- tonsillar bulge, uvular deviation, trismus, and muffl ed voice. Antibiotics2 and aspiration (preferred to s urgical drainage) are needed. Diffi culties arise in examining the throat in an uncooperati ve child and escalate if needle aspi- ration rather than operative incision and drainage is tried.159 Steroids reduce morbidity. There is a limited place for immediate tonsillectomy. Technique for needle aspiration: Learn from a colleague (the carotid artery is nearby). It is common to drain >10mL of pus with immediate bene \201 t. Inci sion may be needed. For technique, see www.clinicaljunior.com/entoncallquinsy.html Parapharyngeal and hypopharyngeal abscesses: Medical therapy alone, especially in children, can resolve these. Lemierre \200\231s syndrome: Pharyngotonsillitis, internal jugular vein thrombo- phlebitis + septic emboli (to lungs, bone, muscle, kidney, liver etc). Cause: Fusobacterium necrophor um. \201\227: High-dose IV benzylpenicillin,2 clindamy- cin & metronidazole). Multiple deb ridments may be needed.160-162 Diff erential diagnosis of unilateral tonsillar enlargement \200 True asymmetry. Do excision biopsy if malignancy possible. \200 Apparent enlargeme nt (shift \200\223 peritonsillar abscess/parapharyngeal mass). \200 Tumors: squamous can cer (70%). Typical patient: Elderly, with sore throat, dysphagia otalgia. Treatment: Rad iotherapy; surgery; cytotoxics. In one study, survival for stage III and stage IV squamous cancer was 79% and 52%, respectively, over 2 \200\22315yrs. 163 Scarlet fever If a rash dev elops on the chest, axillae or behind the ears, which is accentuated in skin folds, 12 \200 \22348h after initial infection ( Pastia lines3 and cir- cumoral pallor and a \200\230st rawberry tongue \200\231) you are probably observing scarlet fever. Start penicillin as tre atment. If after a week the child presents with odd movements, dizziness, walking diffi cul ty or altered consciousness, you may be able to diagnose Sydenham \200\231s chorea or even a post-infectious demyelinating disorder, eg ADEM.4 1 Centor criteria: if T \200\200, pus on tonsils, no cough but cervical adenopathy is pre sent, +ve predictive val- ue for strep throat is 50%; if all 4 are \200\223ve, the negati ve predictive value is 80%. 2 One IV regimen is penicillin 1.2g/6h + metronidazole up to 50 0mg/8h IV \202 uids stat steroid dose. 3 Con \202 uent petechiae in skin creases ( eg at elbow), that may persist as pigmented lines after acute phase. 4 Acute disseminated e ncephalomyelitis (ADEM) develops from antigenic mimicry with antibodies (eg to mycoplasma, streps or EBV) having crossreactivity to CNS epitopes. 164 \201\201 A holistic approach to the person with a sore throat Don \200\231t focus on the t hroat, the swab, or the microbiology: home in on peo- ple \200\231s health beliefs and work to harmonize these beliefs with your own. We often think patients expect antibiotics, and will be disappointed if they are not given. Often this is not the case. Does he attend with every sore throat? If not, why now? \200\234My nephew is coming to stay, and my wife told me to come and get a prescription \200\235 \200\224or symptoms may be worse than usual. If so, ibuprofen may help. But what may really help is dialog. Strangely enough, there is evi dence that rich dialog reduces symptoms rather than merely making them more acceptable.165 565 . s t n e i t a p g n i e b s t n e i t a p p o t s But improving symptoms is not the only aim: dialog may promote pa- tients \200\231 trust in their own body. It may be a stepping stone to active health rather than passive disease. I t may stop your patient being a patient. Don \200\231t do tonsillectomy unless you are sure that \200 Sore throats are in fact due to tonsillitis. \200 5 or more episodes of s ore throat are occurring per year. \200 Symptoms for at least a year. NB: there is now a risk that too few tonsillectomies are being done. More and more adults and children are bei ng hospitalized for throat infections. In 2000 \200\2231, there were 30,942 tonsil-related admissions for medical treatments. By 2008 \200\22309, this had risen to 43,641. entuk.org/ position_papers/documents/tonsillectomy Other indications: respiratory obstruction; suspici on of malignancy. Methods The cold steel method uses good old-fashioned scissors, blades, s nares and sutures. Cautery can be used a microscope; NICE recommends speci \201 c train ing in coblation1 if used. Radiofrequency ablation can shrink tonsils. 166 Complications of surgery (Mortality 1 in 16,000 to 1 in 35,000)167 The worst (but rarely fatal) complicatio n is bleeding. 168 Primary (<24h) often requires a return to theater. Secondary (>24h, but typically after 5 \200\22310 days) is usually due to infection \200\224here repeat surgery is rarely needed: try rest and antibi- otics. Use of the tonsillar gag may cause damage to teeth, the TMJ (p542), and posterior pharyngeal wall. Risk factors for hemorrhage: male; yo unger surgeon, older patient; heat (any kind) used for haemostasis. Use of single-use instr uments (hated by some surgeons) need not cause more bleeding. 169 Management of uncontrolla ble secondary bleeding post-tonsillectomy: \200 Admit. High- \202 ow O2; IVI and resuscit ate until urine \202 ows at >30mL/min. \200 Crossmatch blood and take to theater as need ed. \200 IV antibiotic (co-amoxiclav is an option), 170 eg if T \200\200, neutrophilia, or CRP \200\200.171 Most bleeding is not this severe and can be managed by hydrogen peroxid e gargles, topical vasoconstrictors and admission for IV antibiotics. See Royal College Aud it 2003 www.rcseng.ac.uk/surgical_research_units/docs/National%20Prospec- tive%20Tonsillect omy%20Audit%20Final%20Report%202005.pdf o t s e s a e s i d T N E W O H \200 2009 1 Coblation uses a plasma \201 eld of Na+ created by passing a current through saline to vaporize and dis- sect adjacent tissue: surgical science at the cutting edge. It has less t issue-heating eff ect than diathermy. \200 Stridor Stridor is a musical noise heard in inspiration from partial obstruction at t he larynx or large airways. Sterto is an inspiratory noise like snoring, coming from pharyn x obstruction (its adjective is stertorous; commoner in the obese). \200\207Children \200 \231s airways are narrower and more readily deformed than adult airways, so obstruction hap pens faster and more dramatically. \200\207Look for other signs: swallowing diffi culty/dr ooling, pale/cyanosed, using accessory muscles of respiration; downward plunging of the tra chea with respiration (tracheal tug); all are grave signs and mean impending obstruction. C auses \200 Congenital: Laryngomalacia, web/stenosis, vascular rings. \200 In \202 amma tion: Laryngitis, epiglottitis, laryngotracheobronchitis, anaphylaxis. \200 Tumors: Haema ngiomas or papillomas (usually disappear with onset of 566 \200 immunity \200\224but may require laser treatment before). Trauma: Thermal/chemical \200\224or from intubation. \200 Miscellaneous: Airway or oesoph ageal foreign body; vocal cord paralysis. Laryngotracheobronchitis/croup is the leading cau se of stridor with a barking cough (much commoner than Severity grading of croup172 epiglot titis). 95% are viral, eg parain- 1 Inspiratory stridor barking cough \202 uenza (riba virin can help, eg in im- 2 Grade 1 + expiratory stridor munode \201 ciency). Bacteria (kl ebsiella; 3 Grade 2 + pulsus paradoxus diphtheria) & fungi are rare. If there is 4 Grade 3 + cyanosis or cognition \200\201 cough and no drooling, croup is almost always the diagnosi s. 173 Usually self-limiting; treat at home ( antibiotics). s e s a e s i d T N E Admit (eg to ITU) if severe. In children, CXR may show \200\230steeple sign \200\231 of a tap ering trachea. Give antibiotics, humidi \201 ed O2, + nebulized adrenaline (5mL 1:1000 , may buy time in severe disease needing ventilating), and dexa- methasone 150 g/kg PO sta t or budesonide 2mg nebulized. See also p158. \200 Acute epiglottitis is rarer than croup, eg Managing epiglottitis 9/106/yr, but mortality is high: 1% if respiratory \200 Take to ITU; don \200\231t examine distress. \200 : \200 \211\210 3 : 1. It \200\231s an emerg e ncy as respir- throat (causes resp. arrest) \200 O2 by mask till anaesthe- atory arrest can occur. Often, history is short, tist and ENT doctor arrive septicaemia is rapid, and co ugh is absent. Also: \200 Give nebulized adrenaline, sore throat (100%), fever (88%), dysp noea (78%), voice change (75%), dysphagia (76%), tender an- terior neck cellulitis (27%) , hoarse ness (21%), pharyn gitis (20%), anterior neck nodes (9%), 174 drooling (head for w ard tongue out), prefers to sit, refusal to swallow, dysphagia. Typical cause: Haemophilus (vaccination has reduced prevalence); Strep pyogenes. Laryngomalacia This is the main conge nital anomaly of the larynx ( 60%) appearing within hours of birth (or up to a few months). Immature and \202 oppy aryepiglottic folds and glottis \200\200 laryngeal collapse in i nspiration. Stridor may be most noticeable in certain positions, sleep, or if excited/upset . In 85%, no \200\224 is needed and symptoms usually improve by 2 yrs old. Problems may oc cur with concurrent laryngeal infections or with feeding. 175 Try surgery if severe. It can also develop in association with gastro-oesophageal re \202 ux disease. 176 Laryngeal par alysis accounts for 15 \200\22320% of all those with congenital laryn- geal anomalies. Caus e: Often unknown, but might be from vagal stretching at delivery. Unilateral: May manifest during the 1st few weeks of life with a hoarse, breathy cry that is aggravated by agitation , feeding diffi culties aspi- ration. \201\227: Supportive; most recover by 2 \200\2233 years. Bilateral: Inspiratory stridor at rest that worsens upon agitation signi \201 c ant respiratory distress. \201\227: may need urgent airway intervention (intubation, trach eotomy) surgery. 177,178 IV dexamethasone \200 Visual diagnosis at naso- pharyngeal intubation \200 Blood/epiglottic culture \200 Find cricothyrotomy kit \200 IVI + penicillin G & ceftri- axone 2g/12h IV, p204 \200 Anti pyretic, eg ibuprofen 567 \200 Acute airway obstruction: management in adults \200 Let the patient sit/lie down in the position he is most comfortable. \200 Give O2 or Heliox (79% helium+21% O2; it \200 \231s less dense than air & O2 \200\230 more lam inar \202 ow in obstructed airways, and may reduce work of breathing, respiratory distress, and post-extubation stridor).179 \200 Nebulized racemic adrenaline. \200 Place an IV cannula, give dexamethasone or hydrocortis one IV. \200 Note O 2 saturation, respiratory rate, pulse and blood pressure. \200 Call t he on-call ENT registrar and anesthetist for help (eg via crash bleep). \200 Get the crash tracheostomy kit ready. \200 Brief history from relatives, keeping in view the common cau ses of stridor. \200 Do arterial blood gasses if possible without causing delay or stress. \200 When the stridor improves, do a \202 exible nasendoscopy (ENT registrar) to visual ize the airway,thereby getting an idea about the cause for stridor. \200 Get AP + lateral X-rays of neck & chest. www.clinicaljunior.com/entstridordoddi.html Note on needle cricothy rotomy (OHCM p786) in children \200\224jet O2 at 15L/min through a wide-bore cannula (14G) placed in the cricothyroid membrane: allow O2 in for 1 sec and exhalation (through partiall y obstructed upper airway) for 4sec. Useful in adults too. Fig 2. Relations of the epiglottis. s e s a e s i d T N E If a surgical cricothyrotomy is used (not in children <12yrs; see OHCM p786) a tracheostomy in theater is needed within 30min as jet insuffl ation oxygenates rather than ventilates, so CO2 builds up. Why is this child drooling? Drooling is often normal if <3yrs old (eg associated with teeth ing). So don \200\231t assume that drooling + stridor must mean epiglottitis if drooling pr edated the stridor (chronic causes below). Find out if oral incontinence is from \200\201c erebral control of oral function, hypersalivation, or an obstruction to swallowing. \200 \200 Angioedema/anaphylaxis (p237) \200 Rabies (OHCM p432) \200 Epiglottitis \200 Neur odisability, eg cerebral palsy, bulbar palsy ( \200\201 oro-motor control).180 \200 Muscl e problems (oesophageal dysmotility; cricopharyngeal achalasia) \200 Ingestion of a forei gn body, heavy metals, lithium, or caustic substances \200 Head and neck trauma to swallo wing structures \200 Enlarged tonsils or adenoids nasal polyps/rhinosinusitis/severe t onsillitis \200 Congenital lesions/nasal masses (eg an encephalocele or glioma).1 1 Other causes in adults: ill- \201 tting dentures, re \202 ux oesophagitis, Parkinson \200\231s, stroke, motor neuron disease. \201\227: \200\230SPIT \200\231: scopolamineet a l (anicholinergics \200\201 salivary \202 ow); physio/oral motor training ( palatal tra ining appli- ances), attending to head position, education and training, suction aids, bio- feedback and support; injections of botulinum toxin: gland excisions; transposition or exci sion of ducts.181