ENT Essentials for UKMLA: Common Presentations & Key Diagnostic Approaches

Sore Throat & Tonsillitis: Applying NICE Guidelines for UKMLA Success

Sore throat is an exceedingly common presentation in primary care, and tonsillitis, characterized by inflammation of the tonsils, is a frequent cause of severe sore throat. The vast majority of these cases are viral in origin and self-limiting. For the UKMLA candidate tackling UKMLA ENT presentations like tonsillitis, the primary challenge lies in correctly identifying the small proportion of patients who may benefit from antibiotic therapy, adhering to principles of antimicrobial stewardship, and promptly recognizing potential complications that necessitate further action.

Common Presentations & Differentiating Viral vs. Bacterial

Patients with tonsillitis typically present with a sore throat, odynophagia (pain on swallowing), fever, visibly inflamed tonsils which may have exudate, and tender cervical lymphadenopathy. Differentiating between viral and bacterial causes can be challenging but is important for guiding management.

• Features suggestive of a viral etiology often include coryzal symptoms (runny nose, sneezing), cough, hoarseness, and sometimes diarrhoea; the illness may be generally milder.
• Conversely, features more indicative of bacterial tonsillitis, particularly Group A Streptococcus (GAS), include a more sudden onset, marked fever, visible tonsillar exudate, tender anterior cervical lymph nodes, and a notable absence of cough. These features form the basis of the Centor criteria.

Diagnostic Scoring Systems: FeverPAIN and Centor Criteria

To aid in predicting the likelihood of GAS infection and to guide antibiotic prescribing decisions, clinical scoring systems are employed. NICE recommends the use of the FeverPAIN score.

The Centor Criteria include :

• Tonsillar exudate
• Tender anterior cervical lymphadenopathy
• History of fever (over 38°C)
• Absence of cough

A score of 3-4 suggests a higher likelihood of GAS.

The FeverPAIN Criteria, which NICE advocates, are :

• Fever (in the previous 24 hours)
• Purulence (pharyngeal/tonsillar exudate)
• Attend rapidly (patient presents within 3 days of symptom onset)
• Severely Inflamed tonsils
• No cough or coryza

Each criterion scores one point. The FeverPAIN scoring system is designed to “help identify those who are most likely to benefit from antibiotics”.

NICE Recommendations for Management

NICE guidance emphasizes symptomatic relief and judicious antibiotic use.

• Symptomatic relief: Analgesia with paracetamol or ibuprofen is valuable for managing pain and fever. Patients should also be advised on self-care measures such as rest and adequate fluid intake.
• Antibiotics: For most patients, antibiotics have a limited impact, shortening the duration of symptoms by only approximately 16 hours overall.
• Antibiotic Prescribing based on FeverPAIN score :
  • Score 0-1: Do not offer an antibiotic.
  • Score 2-3: Consider no antibiotic or a delayed/back-up antibiotic prescription. (For adults with a score of 2 or 3, no severe symptoms, and not in a vulnerable group, a delayed prescription is an option).
  • Score 4-5: Consider an immediate antibiotic prescription. (For children with a score of 3 or more, prescribe antibiotics).
• Choice of Antibiotic :
  • The antibiotic of choice is phenoxymethylpenicillin, typically for a 5-10 day course. While 5 days may be sufficient for symptomatic relief in some, a 10-day course is traditionally recommended for proven GAS infection to prevent complications like rheumatic fever.
  • For individuals with penicillin allergy or intolerance, a five-day course of clarithromycin is the alternative first choice. Erythromycin is preferred in pregnancy if there is a penicillin allergy.
  • Amoxicillin should be avoided if there is a possibility of glandular fever (infectious mononucleosis) due to the risk of inducing a characteristic maculopapular rash.

NICE also recommends that “a back-up antibiotic prescription may be considered…[with advice on when to use it]”. This practical advice, including when to start the antibiotic if symptoms don’t improve or worsen, is crucial for UKMLA scenarios and patient communication.

Highlighted Key Point 1: The crucial role of FeverPAIN/Centor scores in guiding antibiotic decisions for tonsillitis, aligning with antimicrobial stewardship principles. For UKMLA candidates, correctly applying these scores demonstrates an understanding of evidence-based medicine and the judicious use of antibiotics, key tenets of safe UK practice.

The application of scoring systems like FeverPAIN moves beyond simple protocol adherence. It facilitates a more tailored approach to antibiotic decisions based on an individual’s risk profile. This nuanced decision-making, which avoids unnecessary medication and potential side effects for those unlikely to benefit, is a clear example of “delivering person-centred care,” a core theme of the UKMLA. This patient-centric approach ensures that treatment is appropriate for the individual, rather than a one-size-fits-all strategy. Furthermore, the evolution of guidelines towards more restrictive antibiotic use for tonsillitis reflects how healthcare systems adapt to emerging evidence on antimicrobial resistance and treatment efficacy. UKMLA candidates are expected to practice within this dynamic, evidence-based framework, demonstrating an understanding that medical practice changes as new evidence becomes available.

Red Flags & Complications

It is vital to recognise warning signs of complications:

• Peritonsillar abscess (quinsy): Characterised by severe unilateral sore throat, trismus (difficulty opening the mouth), dysphagia, a muffled “hot potato” voice, and often deviation of the uvula away from the affected side. This is a clinical emergency requiring urgent referral for assessment and potential drainage.
• Airway compromise: Stridor (a high-pitched breathing sound), difficulty breathing, or drooling are ominous signs requiring immediate emergency management.
• Systemic sepsis: Signs such as high fever, tachycardia, hypotension, or confusion.
• Glandular fever (infectious mononucleosis): Should be considered, especially in adolescents and young adults, if there is a prolonged sore throat accompanied by significant fatigue, widespread lymphadenopathy, and fever. A Paul-Bunnell test or monospot test can aid diagnosis.
• Scarlet fever: If tonsillitis is caused by GAS and is accompanied by the characteristic sandpaper-like rash, a 10-day course of antibiotics is required to manage the scarlet fever and prevent complications.

Indications for Referral/Tonsillectomy

Referral to ENT may be necessary in certain situations:

• Emergency referral: For suspected airway obstruction, peritonsillar abscess (quinsy), or severe systemic sepsis.
• Elective referral for tonsillectomy (NICE criteria for recurrent tonsillitis ):
  • Seven or more clinically significant, adequately treated sore throats in the preceding year.
  • Five or more such episodes in each of the preceding two years.
  • Three or more such episodes in each of the preceding three years.
  • The episodes of sore throat must be disabling and prevent normal functioning.

Epistaxis (Nosebleeds): A Practical Approach for UKMLA Candidates

Epistaxis, or bleeding from the nose, is a very common complaint encountered in various healthcare settings. While most episodes are benign and self-limiting, they can be alarming for patients and, on occasion, can be severe, requiring prompt and effective management. For UKMLA candidates addressing UKMLA ENT presentations such as epistaxis, a systematic approach to assessment, knowledge of immediate management techniques, and understanding when to escalate care or refer are essential.

Common Causes and Sites

A multitude of factors can precipitate epistaxis :

• Trauma: This is the most frequent cause, with nose picking being particularly common, especially in children. Other forms of trauma include insertion of foreign bodies or excessive nose blowing, often associated with URTIs when the nasal mucosa is congested.
• Mucosal Dryness: Environmental factors such as central heating or cold, dry weather can lead to desiccation and cracking of the nasal mucosa.
• Inflammation: Conditions like URTIs, sinusitis, and allergic rhinitis can cause nasal mucosal inflammation and increase friability.
• Medications: Anticoagulants (e.g., warfarin, DOACs) and antiplatelet drugs (e.g., aspirin, clopidogrel) can predispose to or prolong bleeding.
• Bleeding Disorders: Systemic conditions affecting haemostasis, such as thrombocytopenia, von Willebrand disease, or other coagulopathies, can manifest with epistaxis.
• Hypertension: While not always a direct cause, high blood pressure can prolong or exacerbate an episode of epistaxis.
• Less Common Causes: These include vascular abnormalities like hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber syndrome), nasal tumours (e.g., juvenile nasopharyngeal angiofibroma, typically seen in adolescent males), and illicit drug use (e.g., cocaine insufflation, which can cause septal damage).

The site of bleeding is a key determinant of severity and management :

• Anterior Epistaxis: Accounts for approximately 90% of cases. Bleeding typically originates from Kiesselbach’s plexus (also known as Little’s area), a rich anastomosis of blood vessels on the anterior nasal septum. Anterior bleeds are generally easier to control.
• Posterior Epistaxis: Less common (around 10%) but often more profuse and challenging to manage. Bleeding usually arises from branches of the sphenopalatine artery. Blood may be seen running down the posterior pharynx, and there is a higher risk of aspiration and airway compromise.

Systematic Assessment

A thorough assessment is crucial:

• History: Enquire about the onset, duration, and frequency of bleeding, estimate the amount of blood loss, determine if it’s unilateral or bilateral, and identify any provoking factors. A detailed medical history, including any known bleeding disorders, hypertension, current medications (especially anticoagulants/antiplatelets), and family history of bleeding problems, is vital.
• Examination:
  • In cases of severe bleeding, an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach should be adopted first.
  • Monitor vital signs, including pulse and blood pressure.
  • Once initial control measures are in place, attempt to identify the bleeding site (anterior or posterior) using a good light source (e.g., headlamp) and a nasal speculum.

Immediate Management (First Aid & Clinical Setting)

Effective immediate management can often resolve the bleeding:

First Aid Measures :

• The patient should sit upright and lean slightly forward. This position helps prevent blood from being swallowed (which can cause nausea and vomiting) and reduces venous pressure in the nasal vessels.
• Firmly pinch the soft, fleshy part of the nose (anterior nares) continuously for 10-20 minutes.
• Encourage the patient to breathe through their mouth.
• Any blood in the mouth should be spat out.
• An ice pack applied to the bridge of the nose or the nape of the neck may help promote vasoconstriction.

Clinical Setting (if first aid fails):

• Ensure all necessary equipment is readily available: good lighting (headlight), suction, nasal speculum, topical anaesthetic and vasoconstrictor spray (e.g., cophenylcaine, which contains lidocaine and phenylephrine, though age restrictions apply ), silver nitrate sticks for cautery, and nasal packing materials.
• After applying topical spray (if used), wait a few minutes for it to take effect, then gently attempt to locate the bleeding point.

“The MLA content map concentrates on the professional skills, knowledge and behaviours that are essential for safe practice – for example, effective communication, recognising risk and the diagnosis and management of common or acute presentations and conditions.” (Adapted from ).

Managing epistaxis effectively, which includes providing clear instructions to the patient or carers (effective communication) and identifying when simple first-aid measures are insufficient or when the bleeding is severe (recognising risk), directly aligns with these core UKMLA competencies.

NICE CKS Guidance on Cautery & Packing

If bleeding persists despite first-aid measures, further interventions may be required, guided by principles outlined in resources like NICE Clinical Knowledge Summaries (CKS).

• Nasal Cautery (Silver Nitrate):
  • This is suitable for visible anterior bleeding points once active bleeding has been controlled or significantly reduced.
  • Apply the tip of a silver nitrate stick directly to the bleeding vessel for approximately 5-10 seconds. Work from the edge of the bleeding area inwards.
  • A crucial safety point is to avoid cauterizing both sides of the nasal septum during the same session, as this carries a risk of septal perforation.
  • Following cautery, particularly for recurrent bleeds, application of a topical antiseptic cream (e.g., Naseptin®, containing chlorhexidine and neomycin) twice daily for a week or two can help prevent infection and promote healing.
• Anterior Nasal Packing:
  • Indicated if bleeding continues despite sustained pressure and cautery is not possible, not effective, or the bleeding point cannot be identified.
  • Various materials can be used, including prefabricated nasal tampons (e.g., Merocel® , Rapid Rhino®) which expand on contact with moisture, or ribbon gauze impregnated with petroleum jelly or bismuth iodoform paraffin paste (BIPP).
  • The pack should be inserted along the floor of the nasal cavity. Ensure it is firm enough to apply pressure but avoid over-packing, which can cause pain and pressure necrosis.
  • If an anterior pack successfully controls the bleeding, the patient may be discharged with instructions for follow-up, typically within 24-48 hours, for pack removal by a healthcare professional.
  • Prophylactic oral antibiotics are sometimes considered if a nasal pack is to remain in situ for more than 24 hours to reduce the risk of local infection or toxic shock syndrome, though practice varies.
• Posterior Packing: This is a more complex procedure, usually reserved for suspected posterior bleeds that are not controlled by anterior packing. It typically requires specialist ENT input and may involve inflatable balloon catheters or formal gauze packs. Patients requiring posterior packing usually need hospital admission.

The decision to proceed with interventions like cautery or packing involves not only knowledge of the techniques but also an appreciation of the practical skills required and the potential risks, such as septal perforation with bilateral cautery. This underscores that the UKMLA assesses not just factual recall but also procedural understanding and a strong emphasis on safety consciousness, reflecting the practical skills component of the syllabus. When managing epistaxis in elderly patients or those on anticoagulants , a holistic assessment is critical. It’s not merely about stopping the nosebleed but involves considering the patient’s wider medical context, comorbidities, and medications. This broader view, which might involve liaising with other specialists or carefully weighing the risks of reversing anticoagulation, is a hallmark of “delivering person-centred care” and is an implicit expectation for UKMLA candidates.

Table 2: Step-by-Step Management of Acute Epistaxis in a Primary Care/Emergency Setting (NICE CKS based)

This table provides a structured, algorithmic approach to a common acute presentation.