Fever, Painful Ear, Sore Throat, Dizziness & Vertigo

“The presence of fever should trigger the start of an assessment to correctly identify the source of the underlying infection, including more occult causes.”

CAP 14 – Fever

CAP 24 – Painful Ear

CAP 31 – Sore Throat

EM Curriculum: (click to view)

Background

Fever is very common in young children, with between 20 and 40% of parents reporting a feverish illness each year. As a result, fever is probably the commonest reason for a child to be taken to the doctor. Feverish illness is also the second most common reason for a child being admitted to hospital. It usually indicates an underlying infection and is a cause of concern for parents and carers.

Despite advances in healthcare, infections remain the leading cause of death in children under the age of 5 years. The presence of fever should trigger the start of an assessment to correctly identify the source of the underlying infection, including more occult causes.

ENT is a speciality in itself and a wide range of ENT problems present to the emergency department, from epistaxis to the more complex such as Bell's palsy. It is important to recognise when a referral to the speciality team is required.

Learning Outcomes from completing the tasks

  • Consider a differential diagnosis for the feverish child.

  • Apply the NICE guidance for the feverish child to a case example.

  • Recall the correct doses for antipyretics in children.

  • Recognise the different causes of a discharging ear and when to involve ENT.

  • Identify concerning features in the patient presenting with dizziness.

  • Know the course of the facial nerve and how to differentiate facial nerve palsy and Bell's palsy.

Learning Outcome from face-to-face teaching

  • Recognise neutropenic sepsis and recall how to manage it.

    • Be aware of the MASSC score for neutropenic sepsis.

  • Be able to interpret the results of a lumbar puncture and know when to consider the need for one.

  • Be able to identify risk factors for infectious disease.

  • Revise the neuroanatomy and physiology of balance, movement and co-ordination.

  • List the common causes of a sore throat and be able to construct a management plan.

Tasks

Complete the following before the face to face session:

Task 1: Finding the fever

Duration: 45 mins

Read these two blog posts, the first from Don't forget the bubbles summarises an approach to a child with fever.

The second from Life in the Fastlane summarises the NICE guidelines for fever in children.

Task 2: The Discharging Ear

Duration: 30 mins

Watch these two videos from sfo.entuk.org they cover the discharging ear and Otitis media, they cover some key examination points, common organisms and management steps. They do go into some depth and specialist ENT considerations - however having some idea of this level can be helpful when discussing with the ENT or with parents who may have questions about what the specialists will do.

Task 3: Dizzyness vs Posterior Stroke

Duration: 30 mins

"What if I told you that I think that patient you just sent home with vertigo may have been a missed cerebellar stroke? Would you be dialling Risk Management or could you tell me all of the reasons why I’m wrong? Isolated vertigo without other neurological findings can’t be a stroke, right? That is true, if you are doing the right exam, but if you are just doing your standard ED neuro screening exam then you might be missing serious pathology. In this episode of the EMCrit podcast, I discuss how to perform the tests that will differentiate a peripheral cause of continuous vertigo from a cerebellar stroke." – Scott Weingart (EMCrit Blog)

There is also link on the website with a video demonstrating the examination he describes in the podcast.

Task 4: Bell's Palsy vs Stroke

Duration: 30 mins (total time for both articles)

These two articles provide a summary for facial nerve palsy, which is a common presentation to the ED. However it represents a clinical challenge as the key differential is a stroke. The entsho article in particular illustrates that there is a difference between a Bell's palsy and a facial nerve palsy.

#EM3 Content

Lightning Learning:

SimBlog

Mini Teaches:

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“A mother brings her 2 year old son to the emergency department, he has been hot and clingy all day.”
“John, a 72 year old man woke up this morning and felt dizzy when getting out of bed. Since then whenever he stands up or moves he describes a spinning sensation and feels sick.”

Additional Resources

Here are some extra resources to review if you want more information:

PODCAST SUMMARY:

A Canadian document (PDF) summarising the content of a podcast on ENT – Covers the majority of ENT presentations to the ED all on 3 pages.

SKETCHY MEDICINE:

A labeled anatomical diagram of the external ear.

ENTSHO.COM:

A website aimed at provided information on ENT conditions and procedures and making it accessible to all healthcare professionals. Often breaks topics down and includes sections under headings such as "When to admit?" and "When to involve the ENT registrar?"

Bromley Cases of the week:

Two unusual cases of fever to work through:

RCEM Learning:

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: