Background

ENT infections or URTIs are the most common infection of childhood and the most common indication for antibiotic prescribing, yet these are mainly caused by viruses, even in those cases where bacteria are implicated, the disease is often self-limiting. 

This means avoiding, as far as possible, prescribing antibiotics for many URTIs, such as the common cold, most sore throats, congestive otitis, otitis media, and laryngitis with effusion. However, sore throat antibiotics are especially recommended if the rapid antigen tests reveal the existence of GAS. 

For ear infections, reserve antibiotics only for: 

1. Purulent acute otitis media in children under 2 years of age, and 
2. Symptomatic or Advanced forms of purulent acute otitis media in children. 
3. Amoxicillin remains the antibiotic of first choice for the vast majority of ENT infections for which antibiotic therapy is appropriate. In more serious forms of ENT infections, such as epiglottitis, ethmoiditis, para-and retropharyngeal infections, mastoiditis, hospitalization with initial intravenous antibiotic therapy is a matter of medical urgency. 

Epidemiology

A prospective study was conducted for five years to evaluate the epidemiology, distribution and of pattern of Ent emergencies at a tertiary level hospital. The ages of patients ranged from 15 days to 85 years, with 38,793 patients having a male-to-female ratio of 2:1. Epistaxis was the commonest emergency seen in 25.58%. The other common emergencies were aching and discharging ear. The study empahsizes that an ENT emergency ward is definitely necessary for treating serious and potentially life-threatening cases that need urgent evaluation and management by speciliazed physicians. In view of this non-urgency/emergency cases have to be minimized and decreased in order to provide proper care to the emergency cases. 

Anatomy

Pathophysiology

Ear infections 

Infections of the ear can be categorized broadly into otitis media (infections of the middle ear) and otitis externa (infections of outer ear canal).  

Acute otitis media 

Otitis media is an inflammation or infection of the middle ear and mastoid cavity, affecting about 1 in 10 children every year. AOM (acute otitis media) is particularly common in infant sunder 3 years old, with up to 85% experiencing at least one episode by the age of 3. The incidence of AOM peaks between 6 and 12 months, and recurrent AOM affects 10-20% of children by their first birthday. The condition is influenced by host factors, environmental conditions, and microbiological elements, often beginning as a viral upper respiratory infection that leads to a bacterial superinfection. Immunization has significantly reduced both hospital admissions and complications related to AOM in children under 2 years old. 

Otitis externa 

This is an infection or inflammation of the ar canal lining and the underlying bony structure, which can present as either chronic or acute symptoms. AOE(Acute otitis externa) is typically caused by bacterial infections with Staphylococcus aureus and Pseudomonas aeruginosa being common culprits. Mild cases may cause significan t discomfort and itching, whereas COE (chronic otitis externa) is often linked to allergies or inflammatory skin conditions. Symptoms of COE are generally milder and less severe compared to those of AOE. 

Rhinosinusitis (Nasal infections) 

Rhinitis is the inflammation of the nasal lining, whereas sinusitis, also known as rhinosinusitis, involves inflammation of the sinuses. Infective sinusitis can be caused by fungal or bacterial infections and may present as either chronic or acute, with or without nasal polyps. The European Position Paper on Rhinosinusitis provides detailed criteria for diagnosing this condition. 

Acute rhinosinusitis 

ARS (acute rhinosinusitis) is a common condition, affecting 6-15% of the people, and usually starts with a viral infection. Around 0.5-2.0% of ARS cases advance to ABRS (Acute bacterial rhinosinusitis). Several factors can heighten the risk of developing ARS, including climate and seasonal changes, differences in sinus anatomy, ciliary dysfunction, allergies and smoking. Common viruses responsible for ARS include coronaviruses and rhinoviruses. IN cases of ABRS, typical bacteria involved are H.influenzae, S.aureus, S.pneumoniae, and M.cattarrhalis, and various streptococcal species. 

Extracranial complications 

Pott’s puffy and Orbital cellulitis are common conditions encountered in clinical practice. Orbital cellulitis involves inflammation of the orbital tissues, typically originating from an infection of the sinuses. The severity can range from simple inflammation to the formation of pus. Patients often present with a fever and symptoms of an upper airway infection. Key signs of orbital involvement include periorbital edema, proptosis, erythema, ophthalmoplegia, chemosis, and changes in colour perception or visual acuity. If the patient does not improve or worsens with in a 24 to 48 hour period, a CT scan of the sinuses is recommended. In the case of an orbital abscess, the patient should undergo surgical drainage. Management of any potential intracranial complications should involve a multidisciplinary specialist. 

Deep space neck, salivary and Oropharyngeal infections 

Acute tonsillitis is a common infection. It is suffered by both children and adults, while recurring sore throats are suffered by about 100 per 1000 subjects. The infection is usually associate with pharyngitis and is viral in 40-60% of patients. Bacterial tonsillitis accounts for sore throats in up to 30% of children and 15% of adults. In some cases, it may be part of a systemic disease like infectious mononucleosis. Infectious mononucleosis is a common entity in young adults caused by the EBV (Epstein-Bar virus) characterized by splenomegaly, intense system symptoms, liver dysfunction, and acute tonsillar inflammation. Antibiotic therapy should be given for the severe form and if there is no improvement within 48 to 72 hours. Possible complications include deep neck space infections, rheumatic fever, glomerulonephritis, scarlet fever, and quinsy or peritonsillar abscess. 

Acute supraglottitis 

This is a bacterial infection that results in children from the age of 2 to 7 years. It is characterized by sore throat and drooling accompanied by high temperatures. The infection is caused by the H.influenzae type B that has become more common as a result of vaccination, where vaccination has resulted in the decline of the disease. This is an acute emergency to the airways and needs appropriate management in terms of assessment, medical management and intubation. The patient will respond within 24 to 48 hours. 

Salivary gland infections 

Mumps due to paramyxovirus is the most common cause of non-suppurative parotid gland infection, which includes trismus and tenderness associated with general malaise. Treatment is conservative. Recurrent non-suppurative sialadenitis is due to duct obstruction characterized by painful swelling. It may be treated conservatively or by a sialo-endoscopy and duct dilatation or stone extraction. Supurative sialadenitis may be acute or chronic. Its management involves intravenous fluid, antibiotics, and surgical drainage in case of formation of abscess. 

Deep neck space infections 

Neck space infections are very common ENT emergencies that may sometimes even be life-threatening due to airway compromise. The cervical fascia divides them into submandibular, parapharyngeal, retropharyngeal, prevertebral, and carotid spaces. Common causes are tonsillitis, quinsy, odontogenic infections, IV drug users, trauma, foreign body, upper respiratory tract infections, lymphadenitis, sialoadenitis, epiglottitis, and iatrogenic and idiopathic. Most deep neck space infections are polymicrobial, with anaerobic predominance in odontogenic cases and streptococcus in pharyngo-tonsillar infections. In children, this is the most common presentation, affecting cervical lymphadenitis to the retropharyngeal or parapharyngeal nodes with possible abscess formation. In adults, patients can have preceding upper respiratory or dental infections. Extensive deep neck space infections are more common in immunocompromised patients. 

Etiology

ENT infections are related to several pathogens and factors, including those causing infections in the ear, nose, and sinus, throat infections, and systemic conditions. Specific causes include acute otitis media, infection of the nasal and sinus, acute rhinosinusitis, chronic rhinosinusitis, acute tonsillitis, pharyngitis, systemic conditions like infectious mononucleosis and scarlet fever, allergy, environmental factors like smoke, pollution, and allergens, and conditions involving immunodeficiency states. Pathogens and determinants of the conditions, therefore, greatly help in guiding valuable treatment and management options for ENT infections. 

Genetics

Prognostic Factors

The prognosis for ENT infections depends on the type and seriousness of infection, the general health of a patient, and the timeliness of treatment. Some common ENT infections are acute otitis media, otitis externa, acute rhinosinusitis, chronic rhinosinusitis, acute tonsillitis, infectious mononucleosis, and severe ENT infections. Acute otitis media gets better in 1-2 weeks though sometimes there can be a complication of disorganization of the external ear canal or cellulitis. Chronic rhinosinusitis, on the other hand, is more indolent and requires long-term management that may involve nasal corticosteroids and surgery. Acute tonsillitis is a self-limiting disorder that resolves in about a week. Infectious mononucleosis, on the other hand, may have serious complications such as splenic rupture, liver failure, or obstructive airway involvement. More serious ENT infections need to be attended to promptly with hospitalization and possibly intravenous antibiotics. In general, overall health, underlying conditions, and compliance influence recovery and prognosis very much. 

Clinical History

The clinical history of ENT infections involves a comprehensive assessment of onset, duration, symptoms, and any associated factors. This information helps in diagnosing the type of infection and determining the appropriate treatment. 

Ear infections:  

AOM: Symptoms include irritability, hearing loss, fever, ear pain and fluid drainage, often sudden and accompanied by recent upper respiratory tract infections, second hand smoke exposure and ear infection history. 

Otitis externa: Symptoms include ear itching, pain, redness, swelling, and discharge. Acute cases can develop rapidly, often linked to water exposure, earplug use, or eczema history. 

Nasal and sinus infections: 

Acute rhinosinusitis: Symptoms include nasal congestion, purulent discharge, facial pain, reduced smell, cough, sore throat, usually following viral upper respiratory infection, associated with allergies, environmental irritants, or recent infection. 

Chronic rhinosinusitis: Symptoms include persistent nasal congestion, thick discharge, facial pressure, reduced smell, and cough, lasting over 12 weeks. Associated factors include allergies, nasal polyps, or previous sinusitis episodes. 

Throat infections: 

Acute tonsillitis: Severe throat symptoms include difficulty swallowing, fever, and swollen tonsils. Symptoms usually onset suddenly, lasting a few days to a week. Associated factors include streptococcal throat infections. 

Pharyngitis: Acute pharyngitis, characterized by sore throat, redness, fever, and cough, can be caused by recent viral or bacterial infections, allergies, or irritants. 

Systemic ENT conditions 

Infectious mononucleosis: Severe throat, fever, lymph node swelling, fatigue, and liver dysfunction are symptoms of a common infection, typically transmitted through saliva in adolescents and young adults. 

Physical Examination

Ear examination:  

• Inspection and Palpation: Examine the external ear for redness, swelling, or discharge, palpate for tenderness, and use an otoscope to examine the ear canal for signs of infection, cerumen, or foreign bodies. 
• Tympanic membrane examination: The tympanic membrane, typically a pearly gray, translucent substance, can be examined for signs of inflammation, perforation, or fluid behind it. 

Nose examination:  

Examining the nasal bridge and nostrils externally is necessary to look for abnormalities, edema, or asymmetry. An internal examination consists of palpating the frontal and maxillary sinuses for soreness or edema, examining the nasal mucosa, evaluating nasal discharge, and inspecting the nasal septum. 

Throat examination 

• Inspection: Look for lesions, inflammation, and indications of infection in the oral cavity, oropharynx, tonsils, and uvula. Examine the tonsils, pharyngeal walls, and uvula for deviation or swelling, as well as for redness, edema, and exudates. 
• Palpation: Palpate for enlarged or tender lymph nodes in the cervical region. Note for mobility, size, and consistency. 

General examination 

To rule out systemic involvement, monitor vital indicators such as blood pressure, temperature, heart rate, and systemic symptoms such as weight loss, exhaustion, or other infection-related symptoms. 

Age group

Associated comorbidity

1. Asthma 
2. COPD 
3. Allergic Rhinitis 
4. Atopic dermatitis 
5. Diabetes mellitus 
6. Cleft palate 
7. Deviated nasal septum 
8. GERD 
9. Autoimmune diseases 
10. Tuberculosis 

Associated activity

Acuity of presentation

Differential Diagnoses

Ear infections 

1. AOM 
2. COM 
3. Mastoiditis 
4. Eustachian tube dysfunction 
5. Barotrauma 
6. Otitis media 

Nasal and sinus infections 

1. Acute sinusitis 
2. Rhinitis 
3. Chronic sinusitis 
4. Nasal polyps 
5. Viral upper respiratory infections 

Throat and pharyngeal infections 

1. Acute Pharyngitis 
2. Tonsillitis 
3. Peritonsillar abscess 
4. Laryngitis 
5. Epiglottitis 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Treatment for ENT infections consist of treatment for the basic cause, reduction of symptoms, and prevention of complications. Among common ENT infections are AOM, which is an acronym for acute otitis media; otitis externa, also known as PEO or swimmer’s ear, chronic otitis media, mastoiditis, infections in the nasal passages and the sinuses, rhinitis, infections of the throat and pharynx; and lastly, epiglotitis. 

Ear infections involve AOM, which requires to be treated with antibiotics and pain management. Chronic otitis media typically requires both oral or topical antibiotics and surgical intervention. Mastoiditis also needs treatment with antibiotics and often necessitates surgical intervention. Nasal and sinus infections encompass conditions such as acute and chronic sinusitis, allergic rhinitis, and infections of the throat and pharynx. Throat and pharyngeal infections include acute pharyngitis, tonsillitis, peritonsillar abscess, laryngitis and epiglottitis.

Treatment for these infections generally involves symptomatic management, hydration, analgesics, throat lozenges and antibiotics. Preventive measures such as maintaining good hygiene, vaccination, and avoiding known irritants or allergens, are also important. Treatment plans should be individualized based on the patient’s age, any existing comorbid conditions, and the severity of the infection. For accurate diagnosis and effective management, healthcare professionals should be consulted. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Use of antibiotics

• Amoxicillin: This is used as a first-line of drug intreating ENT infections. This belongs to the group of penicillin antibiotics. 
• Cefazolin: It belongs to the class of cephalosporins. It is used as an alternative for antistaphylococcal penicillins. 
• Metronidazole: It is particularly used in treating acute bacterial otitis externa. 

use-of-phases-of-management-in-treating-ent-infections

ENT infections can be managed through a structured approach. This includes assessment and diagnosis, immediate management, initial treatment, specific treatment, monitoring and follow-up, prevention and education, and long-term management. 

The first step of clinical assessment consists of an exact history of symptoms, previous treatments, and the history taken during medical checkups. The second step is diagnostic work-u involving laboratory tests and imaging studies with microscopic testing. The third is immediate management, which is provided for pain management, hydration, rest, etc.

The fourth is specific treatment such as tailored therapy, surgical intervention, support care. The fifth phase is that of follow-up which means watching, observing and assessing the response to the treatment. Diagnosis may be performed again if the symptoms persist or worsen. The sixth phase is long-term management of chronic conditions, such as chronic sinusitis or recurrent otitis media, with regular follow-ups. By working through these phases, ENT infections can be quite effectively dealt with to achieve optimized patient outcomes with reduced chances of complications by any treating healthcare professional. 

Medication

Future Trends

Media Gallary

References

Infections and foreign bodies in ENT – PMC (nih.gov) 

Antimicrobial treatment of ENT infections – PubMed (nih.gov)