EAR, NOSE AND THROAT
CASE 82: Sore throat
history
A 28-year-old man arrives at the emergency department complaining of a sore throat. The pain has been increasing over the last few days and he is now finding it difficult to open his mouth. He has stopped eating and is only tolerating small amounts of fluid. Two days ago he saw his general practitioner, who prescribed him some oral antibiotics and analgesia for a mild tonsillitis. He suffers with asthma.
examination
He appears uncomfortable and has difficulty in speaking as a result of his pain. His blood pressure is stable, but his temperature is 39.0°C and his pulse rate is 115/min. His oxygen saturation is 98 per cent on room air. Oral examination, with a tongue depressor, is difficult due to trismus, but reveals a unilateral left-sided tonsillar swelling with a diffuse oedematous ‘bulge’ superior and lateral to the tonsil. As a result, the uvula is deviated to the contralateral side. The left tonsil has some exudate on its surface. There is a palpable jugulo-digastric lymph node on the left. The rest of the examination is unremarkable.
INVESTIGATIONS
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Normal |
haemoglobin |
14.8 g/dl |
11.5–16.0 g/dl |
White cell count |
18.0 3 109/l |
4.0–11.0 3 109/l |
platelets |
301 3 109/l |
150–400 3 109/l |
Questions
•What is the diagnosis?
•What is the initial management?
•What is the differential diagnosis?
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100 Cases in Surgery
ANSWER 82
The patient has a left-sided quinsy or peritonsillar abscess. This occurs between the palatine tonsil and the pharyngeal muscles. It typically develops from an untreated or ineffectively treated acute tonsillitis. The typical presentation has been described, but in addition patients may complain of headaches and referred pain to the ear or neck. Malaise, dehydration and trismus are common features. Cultures from aspirates often show mixed aerobic and anaerobic organisms, the commonest being Streptococcus pyogenes.
The initial management involves:
•Analgesia
•Intravenous fluid administration for dehydration
•Administration of broad-spectrum antibiotics, e.g. co-amoxiclav
•Consideration of intravenous steroids if severe or risk of airway compromise
•Needle aspiration or incision and drainage of abscess
!Differential diagnoses
•peritonsillitis
•pharyngitis/parapharyngeal abscess
•Dental infection
•infective mononucleosis
•lymphoma
•internal carotid artery aneurysm
•other causes of parapharyngeal swellings, e.g. salivary gland mass, infection, calculi
KEY POINTS
•although rare, patients with a quinsy can present with acute respiratory compromise necessitating prompt assessment by an ent and/or anaesthetic specialist.
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Ear, Nose and Throat
CASE 83: epiStaXiS
history
A 71-year-old woman attends the emergency department with a severe nosebleed. The bleeding started an hour before and is causing the patient a great deal of distress. She is not known to have any bleeding abnormalities. Previous medical history includes hypertension, angina and hypercholesterolaemia. She takes aspirin 75 mg od, bendrofluazide 2.5 mg od, isosorbide mononitrate 30 mg bd and simvastatin 40 mg nocte. She has no known allergies and she is an ex-smoker.
examination
Her blood pressure is 172/103 mmHg and her pulse rate is 91/min. The oropharynx appears normal, with no evidence of blood draining in the posterior pharynx. Inspection of the nasal cavity using a speculum and light source suggests a bleeding point from the left nostril. There are no masses seen and there is no palpable cervical lymphadenopathy. The cardiovascular and respiratory examinations are normal.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
12.3 g/l |
11.5–16.0 g/dl |
White cell count |
8.0 3 109/l |
4.0–11.0 3 109/l |
platelets |
209 3 109/l |
150–400 3 109/l |
Coagulation profile: normal |
|
|
Questions
•How is epistaxis classified?
•What is Little’s area?
•What is the aetiology?
•What is the basic management of epistaxis?
193
100 Cases in Surgery
ANSWER 83
Epistaxis is defined as acute haemorrhage from the nasal cavity or nasopharynx. It is classified into anterior (anterior nasal cavity) or posterior (posterior nasal cavity and nasopharynx). Anterior bleeding is more common. It is commoner in the winter months when upper respiratory tract infections are more frequent.
Little’s area refers to Kiesselbach’s plexus, a network of blood vessels on the anterior portion of the nasal septum (feeding vessels from superior labial, greater palatine and anterior ethmoid arteries). This is the commonest point of bleeding in the anterior nasal cavity. Posterior bleeding tends to occur from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx.
!Aetiology
• Local: |
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Foreign body |
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idiopathic |
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• |
irritants, e.g. chemicals, cigarette |
• |
local trauma, e.g. nose picking/nasal |
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smoke, recreational drug use |
• |
bone fracture |
• |
Systemic: |
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iatrogenic, e.g. nasopharyngeal/nasogastric |
• |
bleeding disorders, e.g. |
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• |
intubation |
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haemophilia, platelet dysfunction, |
infection/inflammation, e.g. upper respira- |
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thromobocytopaenia |
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• |
tory tract infection/sinusitis/rhinitis |
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• |
leukaemia |
neoplasia |
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• |
liver disease, e.g. cirrhosis |
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• |
Septal perforation/deviation |
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medication, e.g. non-steroidal |
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vascular anomalies, e.g. arteriovenous |
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anti-inflammatory drugs, aspirin, |
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malformation, telangectasia |
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heparin, warfarin |
The basic management involves:
•An assessment of the patient’s airway, breathing and circulation. Severe epistaxis may require endotracheal intubation. This is extremely rare.
•Manual compression of the nasal cavity (cartilaginous part of the nose) by asking the patient to grasp his nose and sustain pressure continuously for 10 min in an attempt to arrest the bleeding. Position the patient upright and ask him/her to lean forward over a bowl to try and avoid swallowing blood.
•Regular observations.
•Obtaining intravenous access and commencing intravenous fluids in patients with significant haemorrhage.
•Taking blood for a haemoglobin estimation and a crossmatch in cases of significant haemorrhage; a coagulation profile is not routinely indicated unless patient is taking anticoagulants or a coagulopathy is suspected, e.g. liver disease.
•Views can be improved by putting pledgets soaked with vasoconstrictor/local anaesthetic into the nose. This may help to identify the site of bleeding.
•If a bleeding site is identified, a silver nitrate stick can be applied to the bleeding point to try to cauterize the bleeding after the administration of topical local anaesthetic.
•If the above measures prove unsuccessful, the anterior part of the nose should be packed with nasal tampons. An urgent ear, nose and throat (ENT) review should be requested if bleeding persists.
KEY POINTS
•epistaxis can be life-threatening.
•if initial measures fail to control the bleeding, an ent specialist should be sought.
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