Ear, Nose & Throat

• Most acute tonsillitis is viral, not bacterial — group A strep is the main bacterial cause worth treating, but it's the minority.
• Most sore throats are simple tonsillitis, not a peritonsillar abscess (quinsy) — trismus, uvular deviation and a muffled "hot potato" voice point towards quinsy and need same-day ENT assessment.
• Avoid amoxicillin/ampicillin where infectious mononucleosis (EBV) is possible — it classically triggers a widespread maculopapular rash in glandular fever.

• Exam findings: soft palate fullness with loss of the peritonsillar arch, uvula deviated away from the affected side, trismus, and a muffled "hot potato" voice.
• Key differential: peritonsillar cellulitis — diffuse inflammation without a drainable pus collection, which can progress to a true abscess if untreated.
• Diagnosis is clinical ± bedside intraoral or transcervical ultrasound; CT is not routinely needed for a typical presentation — reserve it for atypical features, suspected deep neck space extension, or when trismus prevents an adequate exam.

Refer to ENT for the procedure itself — a tongue depressor, good lighting and patient cooperation (trismus can make this difficult) are needed throughout.

• Practical procedural points: written consent, a 20mL syringe for aspiration, and drain with a capped/guarded 18-gauge needle — capping limits insertion depth and helps avoid the carotid sheath, which sits close by.
• Pre-procedure adjuncts some operators use: co-phenylcaine spray, glycopyrrolate to dry secretions and improve the view, and nebulised adrenaline with lidocaine.
• CT neck specifically if retropharyngeal or other deep neck space extension is suspected (see the diagnosis note above).
• After drainage: oral augmentin for 7 days, plus warm salt water gargles for comfort and hygiene.

• Obstructive sleep apnoea attributable to tonsillar hypertrophy.
• Paradise criteria for recurrent tonsillitis: ≥7 episodes in 1 year, or ≥5/year for 2 years, or ≥3/year for 3 years.
• Recurrent peritonsillar abscess (typically ≥2 episodes).
• Suspected malignancy.

• Sit the patient up and lean forward to protect the airway from pooling/aspirated blood.
• Two large-bore IV cannulae, IV fluids, and bloods including FBC, coagulation studies and a group & hold (crossmatch if bleeding is significant).
• TXA IV as an adjunct while arranging definitive management.
• Temporising measures for visible ooze: co-phenylcaine (lidocaine + phenylephrine) spray, or adrenaline-soaked gauze held to the tonsillar bed.

• Largely a clinical diagnosis — deformity, swelling and epistaxis after trauma. Plain X-ray of the nasal bones rarely changes management and isn't routinely needed.
• Before treating the fracture itself, actively exclude: septal haematoma (needs urgent drainage — untreated it can cause cartilage necrosis and a saddle-nose deformity), CSF rhinorrhoea, and other serious head injury.
• Any open wound over a nasal fracture needs antibiotic cover. Cat bites specifically carry a high risk of Pasteurella multocida and are treated with amoxicillin-clavulanate.

Closed reduction is ideally performed once swelling has settled but before the bones fixate — commonly around day 5–10 post-injury in adults (children heal faster and are usually reduced sooner).

• History: anticoagulant/antiplatelet use, recent nasal surgery, trauma, hypertension. Review anticoagulation rather than reflexively ceasing it — weigh bleeding risk against the patient's thromboembolic risk.
• First aid: sit upright, lean forward (stops swallowed blood), firm continuous compression of the soft cartilaginous lower part of the nose for at least 15–20 minutes.
• Adjuncts: topical vasoconstrictor (oxymetazoline), TXA- or adrenaline-soaked gauze/pledgets, silver nitrate cautery for a visible anterior bleeding point (classically Little's area).
• If not controlled: nasal tampons or a balloon device (e.g. RapidRhino). Avoid packing both sides at once where possible — bilateral packing raises the risk of septal pressure necrosis.

A posterior bleed — anterior measures fail, or bleeding is visible tracking down the oropharynx — needs ENT referral and usually admission.

• Swab if severe, recurrent, or not responding to first-line treatment.
• Aural microtoileting (gentle irrigation or microsuction) clears debris and improves topical drug penetration.
• Keep the ear dry — no swimming, use a plug when showering.
• Topical ciprofloxacin drops ± an ear wick if the canal is swollen shut.
• Topical antifungals for confirmed or suspected fungal otitis externa (otomycosis) — use a non-ototoxic formulation if there's any possibility of a perforated tympanic membrane.

Usually follows a viral upper respiratory tract infection causing eustachian tube dysfunction — most common in young children. Ear and jaw/TMJ pain can refer in either direction via shared sensory innervation, so a normal-looking ear with ongoing pain should prompt examination of the teeth and TMJ for a referred cause.

• Analgesia is first-line regardless of whether antibiotics are given.
• Consider antibiotics for: age under 2 years, immunocompromise, bilateral disease in a young child, perforated TM/otorrhoea, systemic illness, or symptoms not improving after 48–72 hours of watchful waiting.
• Amoxicillin is first-line; use amoxicillin-clavulanate if a beta-lactam was given in the last 30 days, there's been treatment failure, or there's a history of recurrent AOM.

• Complications: conductive hearing loss, otitis media with effusion (OME), mastoiditis (boggy, tender postauricular swelling with a protruding ear — can cause facial nerve palsy via the nerve's course through the temporal bone), and rare intracranial spread (meningitis, epidural abscess).
• Suspected mastoiditis: CT petrous bones to define extent, start IV antibiotics and involve ENT urgently.
• OME usually resolves within 3 months; persistent effusion beyond that — especially bilateral, with hearing loss — warrants ENT referral to consider grommets.

• A firm, fixed (rather than mobile) node raises concern for malignant infiltration.
• In an adult with risk factors (smoking, alcohol), the most common cause of a malignant cervical node is metastatic squamous cell carcinoma from the upper aerodigestive tract (oral cavity, oropharynx, larynx, hypopharynx) — work-up for an unknown primary includes ENT examination with nasoendoscopy, fine-needle or core biopsy of the node, and cross-sectional imaging ± panendoscopy.
• If a thyroid primary is suspected, note that papillary thyroid carcinoma (around 85% of thyroid cancers) is well known for presenting as a lateral neck node metastasis even when the primary tumour in the thyroid itself is small or occult.

The submandibular gland is the most common site for salivary duct stones (sialolithiasis) — its saliva is more viscous and alkaline, and Wharton's duct runs an uphill course with a narrower distal opening, all of which favour stone formation.

• Live insect in the ear canal: instil oil or topical lignocaine to kill/immobilise it before attempting removal.
• Consider procedural sedation (e.g. ketamine) for a distressed child needing a more invasive removal.
• Nasal FB removal options: direct visualisation with instruments, a suction catheter, positive-pressure techniques ("parent's kiss") in a cooperative child, or cyanoacrylate glue on a cotton bud touched to a smooth round object and withdrawn once adhered.

A suspected oesophageal food bolus impaction can sometimes be helped along with a trial of a fizzy drink (the "Coca-Cola technique") ± glucagon. This is for suspected food bolus only — never for a suspected sharp object or button battery — and shouldn't delay endoscopy if it fails or red flags are present (drooling, complete obstruction, chest pain).

• Causes to consider: foreign body, anaphylaxis, malignancy, quinsy/odontogenic abscess, infective (e.g. epiglottitis) or inflammatory causes.
• For an infective/inflammatory threat: IV antibiotics, nebulised adrenaline as a temporising measure, IV dexamethasone, and urgent ENT/anaesthetic involvement — may need a controlled airway in theatre.
• Flexible nasoendoscopy by ENT is the key tool to directly visualise the airway when compromise is suspected — done cautiously with senior/anaesthetic support on standby, given the risk of precipitating complete obstruction.