6) ear, eye, nose, skin, throat (ie special senses) Flashcards

Question

LABBYRINTHITIS: - how is diagnosis normally made? - investigations to consider if diagnosis is uncertain or suspect more sinister cause? 6

Answer 1

Diagnosis is largely CLINICAL (ie based on hx and exam) nb glucose is helpful in excluding hypoglycaemia. in most patients with suspected viral labyrinthitis, no other investigation is necessary OTHER - pure tone audiometry (to assess hearing loss) - FBC + blood culture (if systemic infection suspected) - culture and sensitivity testing (if any middle ear effusion) - temporal bone CT scan (if suspecting mastoiditis or cholesteatoma) - MRI scan (can rule out causes such as suppurative labyrinthitis or central causes of vertigo) - vestibular function testing (may be helpful in difficult cases and/or determining prognosis)

Answer 2

Emergency admission + see ENT specialist if sudden onset U/L hearing loss prognosis for viral labyrinthitis: Good. Benign & self-limiting. Majority of cases take several days to few weeks to resolve completely ADVICE - Avoid driving/operating machinery - During acute attacks, lie still w/ eyes closed Medication: PROCHLORPERAZINE for dizziness (nb this is a 1st gen anti-psychotic - so can haveEPSEs with it!)

Answer 3

55 years = average onset vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards) nb may be associated with nausea each episode typically lasts 10-20 seconds positive Dix-Hallpike manoeuvre nb usually resolves spontaneously after a few weeks to months Symptomatic relief may be gained by: - EPLEY manoeuvre (successful in around 80% of cases) nb can also teach the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises nb Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value

Answer 4

a non-cancerous growth of squamous epithelium that is 'trapped' within the skull base causing local destruction presents in childhood - congenital (epithelium trapped in bone during embryogenesis) - cleft palate (causing eustacian tube dysfunction) - tympanic membrane trauma (norm secondary to otitis media) main two features: 1) PROGRESSIVE unilateral conductive hearing loss 2) Painless PURULENT FOUL smelling discharge (otorrhea) – frequent + unremitting nb depending on size, can also get: - vertigo - facial nerve palsy - cerebellopontine angle syndrome

Answer 5

Otoscopy - 'attic crust' - seen in the uppermost part of the ear drum (with drum retraction or perforation) Management - patients are referred to ENT for surgical removal

Answer 6

aka herpes zoster oticus is reactivation of VZV in CN7 (ie shinges in facial nerve) 1st) AURICULAR PAIN other symptoms - facial nerve palsy - vesicular rash (around ear and tongue) - vertigo + tinnitus Mx - PO aciclovir - steroids

Answer 7

primary otalgia is pain orginiting from pathology in the ear - secondary is when pts feel pain in the ear but this is actually referred from somewhere else ``` PRIMARY OTALGIA = infection (commonest!) = trauma + foreign bodies = impacted ear wax - ramsay hunt syndrome - otologic neoplasms ``` ``` SECONDARY OTALGIA = dental inflammation / infection = temporomandibular joint disorders (pain worse w chewing) = trigeminal neuralgia = temporal arteritis - head + neck cancers - eagle's syndrome ``` Nb Eagle's syndrome is a condition associated with the elongation of the styloid process or calcification of the stylohyoid ligament, clinically characterised by throat and neck pain, radiating into the ear. ALWAYS find a cause for otalgia!!! - don't just treat with analgesia! - if not resolving with eg Abx for suspected infection, refer to ENT

Answer 8

- progressive or sudden hearing loss - loss of vision (temporal arteritis) - black spots in vision - dysphagia - odynophagia - dysphonia - hamoptysis (head + neck Ca) - weight loss - immunosuppressed - diabetes (rapidly proggressing infection)

Answer 9

CONJUNCTIVA - thin layer of tissue that covers whole eye EXCEPT cornea IRIS - coloured bit of the eye SCLERA - white of eye PUPIL - black bit CORNEA - transparent tiny lens that covers iris, pupil and anterior chamber (conjunctiva doesn't cover this bit!) ANTERIOR CHAMBER - front part of the eye between the cornea and the iris nb posterior chamber is between iris and lense (then aqueous chamber if actually in main part of your eyeball)

Answer 10

``` ACUTE ANGLE CLOSURE GLAUCOMA = elderly, long-sited pt, sudden pain in/behind eye, reduced visual acuity, halos 2) conjunctiva: injected 3) iris: injected 4) pupil: FIXED MID-DILATED (can be oval) 5) cornea: steamy/hazy 6) anterior chamber: very shallow 7) intraocular pressure: very high! ``` ANTERIOR UVEITIS (iritis) = HLA-B27: ank spond, RA, reactive arthritis, sarcoid etc, photophobia, deep boring pain - worse with acomodation 2) conjuctiva: injection most marked around cornea (ie red ring around iris) 3) iris: injected 4) pupil: SMALL +/- irregular shape(dt adhesions) 5) cornea: NAD 6) anterior chamber: TURGID (CELLS! = HYPERPYON) 7) IOP: NAD ``` SCLERITIS = half have rheum diseases, pain - esp on eye movement 2) conjunctiva: injection, is most marked around cornea (ie red ring around iris - nb similar to iritis) - also has BLUISH HUE 3) iris: ?? 4) pupil: NAD 5) cornea: NAD 6) anterior chamber: NAD 7) IOP: NAD ``` ``` CONJUNCTIVITIS = norm bilateral, bacterial, viral or allergic 2) conjuntiva: injected (greatest towards medial and lateral corners of eyes), discharge (purulent if bacterial) 3) NAD 4) NAD 5) NAD 6) NAD 7) NAD ``` ``` SUBCONJUNCTIVAL HAEMORRHAGE = norm secondary to valsalva manouvere, HTN, bleeding disorders, trauma, haemorrhagic fevers 2) bright red area of sclera 3) NAD 4) NAD 5) NAD 6) NAD 7) NAD ```

Answer 11

``` ACUTE ANGLE CLOSURE GLAUCOMA - IV acetazolamide (500mg) - Pilocarpine eye drops (after 1 hr) (see specific flashcard for more info) = refer ASAP ``` ANTERIOR UVEITIS (iritis) - steroid eye drops (eg pred) - atropine eye drop = refer ASAP SCLERITIS - oral NSAIDs is 1st line = refer ASAP CONJUNCTIVITIS - depends on cause (antihistamine for allergic, consider chloramphenicol if bacterial) = no referral needed SUBCONJUNCTIVAL HAEMORRHAGE - none, resolves spontaneously - check BP and if on anticoags = refer (only if traumatic cause)

Answer 12

pupil dilates -> iris pushes against lense -> aqueous can't drain from posterior to anterior chamber -> trabecular meshwork also blocked -> aqueous cannot drain from anterior chamber -> RAISED intraocular pressure this is sight threatening as the raised IOP can -> death of optic nerve nb normally aqueous humoour is produced by ciliary bodies in posterior chamber then moves to anterior chamber where it is drained in the trabecular meshwork nb vitreous humour is is in the deeper part of the eye - different to aqueous humour)

Answer 13

generally elderly (also asians at higher risk) long-sighted at higher risk (hyperopia) - dt shallow anterior chamber nb you get more long-sighted as you age!! drugs which can increase likelihood: - sympathomimetics - anticholinergics ^both dilate pupil!! acute trigger is normally low light (eg in evening) as pupil dilates! nb can also get it secondary to a traumatic haemorrhage (which pushes the posterior chamber anteriorly)

Answer 14

HALOES / rainbows around lights!! constant aching pain develops RAPIDLY around one eye - reduced vision - pain radiates to forehead (headache) - nausea and vomiting - abdo pain

Answer 15

reduced visual acuity perilimbal conjunctival injection (ie closest to the iris/cornea) iris injected pupil FIXED (ie not responsive to light) MID-DILATED HAZY cornea (also hard on palpation) anterior chamber: shallow but NO cells (how differentiate from anterior uveitis) raised IOP

Answer 16

opthalmologist! - SUPER URGENT! (even OOH) - lie patient on back (no pillows) - DON'T put on eye mask or dim light (this will dilate pupil more, making worse!) 1) IV ACETAZOLAMIDE (500mg) - this works by reducing aqueous secretions 2) PILOCARPINE EYE DROPS (after 1 hr) - parasympathetic -> constricts pupil which opens trabecular meshwork, allowing drainage nb can also give betablockers (if not CI) topically (timolol eye drops!) ALSO PRESCRIBE - oromorph - ondasetron ``` DEFINITIVE MANAGEMENT: Peripheral iridectomy (laser or surgery) – do once IOP is controlled, involves removing iris segment at 12 oclock B/L to allow aqueous flow ```

Answer 17

INFLAM / AUTOIMMUNE - anterior uveitis / iritis - scleritis - episcleritis - allergic conjunctivitis INFECTIOUS - viral conjuctivitis - bacterial conjuctivitis SECONDARY TO FOREIGN BODIES - corneal abrasions / foreign bodies - bacterial or fungal keratitis / corneal ulcer (almost always secondary to contact lenses!) OTHER - acute angle closure glaucome - subconjuctival haemorrhage nb subconjunctival haemorrhage can be caused by: trauma, straining (coughing, sneezing, vomiting, Valsalva), conjunctivitis, chronic health conditions (diabetes, hypertension), and coagulopathy CONJUNCTIVITIS is COMMONEST cause of acute red eye!

Answer 18

'BILATERAL generalised conunctival injection' nb injections tend to be more peripheral nb conjunctivitis = most common cause of acute red eye - bacterial - viral - allergic nb all three very common

Answer 19

'uncomfortable', gritty eyes (rather than painful) - erythema of conjunctiva - watery eyes - itchy eyes viral more 'itchy' and watery discharge while bacterial is more 'sticky' with a more purulent discharge (clinically hard to tell the difference between) allergic - eyelid swelling +/- conjunctival oedema - history of other atopic disease

Answer 20

use a cold compress PO antihistamines OR TOP anti-histamines e.g. Emedastine or olopatadine Nb can also have steroid drops if really bad - but these would be started by opthalmologist

Answer 21

CHLORAMPHENICOL eye drops (or fusidic acid) controversial - most BACTERIAL infections resolve within 5 days without treatment (can give delayed prescription) ALWAYS GIVE Abx to: - purulent, painful, red - dry eyes / known eye disease - contact lense user - care / ICU / nursery workers - children at nursery

Answer 22

suspect could be gonococcal or chlamydial cause! DO EYE SWABS!! and refer to opthalm refer NEONATES to opthalm straight away as most likely to be chlamydia/gonococcal from mothers birth canal

Answer 23

``` BACTERIAL = strep pneumoniae = staph aureus = H. influenzae - gonococcal - chlamydial ``` VIRAL = adenovirus (80%) ^very contagious!!

Answer 24

URTI norm preceeds (or contact with someone with conjunctivitis - eg in home) 1-2 weeks (but can be as long as 6 weeks!) - refer at 6 weeks

Answer 25

Otitis media or LRTI

Answer 26

= red eye = watery eye = painful eye = sensation of foreign body in eye = blurred vision (nb degree of loss of visual acuity doesn't correlate with severity) (nb foreign body on cornea is more painful than on sclera) PHOTOPHOBIA (always suggests corneal involvement, superficial or deep)

Answer 27

Conjunctival or ciliary injection (ALL) FLUROSCEIN STAIN (appears green under blue light if any epithelial damage) RED FLAGS - distorted iris / pupil (or globe) - air bubbles under cornea - leaking humour - hyphaema (blood level in iris) -BAD SIGN! - subconjunctival haemorrhage (only if massive and hx of trauma!) nb see many of these with eyes alone - but can use a slit lamp too (but norm would just refer to opthalm to do this if unsure!) SHOULD ALWAY EVERT EYELIDS to look for abrasians / foreign bodies nb also loss of red reflex (loose in blood in vitreous or large retinal detachment)

Answer 28

Seidel’s test = 10% Fluorescein (dark orange) check if aqueous fluid is leaking (treat as open globe injury)

Answer 29

- all high-velocity injuries caused by sharp objects - chemical inj. - FBs - ↓visual acuity - large abrasion (>60% cornea) - corneal opacity - rust ring - distorted pupil - retinal damage - deep laceration of orbit etc. BASICALLY REFER ANYTHING that is worse than a simple, small corneal abrasion with no foreign

Answer 30

CORNEAL ABRASION - TOP anaesthetics - TOP chloramphincol (fusidic acid if pregnant) IF foreign body, ALSO: - remove FB under TOP anaesthetic - irrigate eye with water (then do as above!)

Answer 31

Do NOT touch, manipulate or pad the eye REFER IMMEDIATELY Give rigid eye shield to protect eye and refer immediately Give TETANUS shot

Answer 32

CONTACT LENSE WEARERS can be bacterial (commonest), viral (norm HSV) or rarely fungal YES - REFER URGENTLY!

Answer 33

may start with a 'foreign body sensation' then - photophobia - blurred vision - discharge - pain

Answer 34

- severe conjunctival injection - discharge - eyelid swelling corneal ulceration demonstrated by fluorescein stain

Answer 35

opthalmologists manage slit lamp - to determine if bacterial or vioral ulcer (look different) - TOP chloramphenicol (or other Abx) OR - TOP acyclovir ^depending on cause identified!

Answer 36

gradual deposiotion of opaque protein deposits onto lense - increased age - female - smoking - UV exposure - diabetes mellitus - inflammatory eye disease - corticosteroids

Answer 37

TORCH - toxoplasmosis - other (VZV, syphillis, HIV) - rubella - CMV - herpes simplex down's yndrome nb can also get idiopathic congenital cataracts

Answer 38

GRADUAL (see nb below) PAINLESS blurred vision, slowly -> loss of vision (esp if bilateral) nb often both eyes but norm one worse than other - trouble with nocturnal vision - difficulty reading (↓Acuity) - failure to recognise faces - problems watching TV / see colour less clearly = DAZZLE / GLARE (esp in sunlight or lights whilst driving at night - "is like driving with a dirty windscreen at night/bright light") = HALOES (around bright lights) nb normal gradual onset 'nuclear' cataracts - but can get posterior sub-capsular cataracts which progress faster (norm secondary to STEROIDS)

Answer 39

``` RED REFLEX (absent in congenital cataracts and retinoblastoma) - part of newborn check! ``` if missed may notice: - squint - amblyopia (lazy eye) - nystagmus need to operate fast (ideally within 4 weeks) or seeing part of brain won't develop properly!

Answer 40

red light reflex - present if early - absent if late Lens appears brown or white if bright light shone refer to opthamlmologist (routine) for slit lamp diagnosis if considering surgery

Answer 41

- stop smoking - wear sunglasses surgery is only cure - operate on one eye at a time can only drive if: - In daylight be able to read a number plate at a distance of 20m - Visual acuity must be at least Snellen 6/12 with both eyes open (or in the only eye if monocular) ^if worse than this - must inform DVLA and not drive! operate if: - QoL↓ - unable to read number plate @ 20m ALWAYS DIOCUMENT VISUAL ACUITY (on any referral!)

Answer 42

``` MEIBOMIAN CYST - aka chalazion - blocked meibomian gland (norm hydrates eye) -> cyst - NON-infective = NOT tender (may be painful initially) = HARD on palpation ``` ``` STYE - aka hordeolum - infected meibomian gland (internal) or lash follicle (external) = INFECTIVE (basically a mini abscess) = SOFTER on palpation ``` BOTH - single lump on eyelid - can get watering and slightly red eye nb both can have a yellowy centre - but stye often more pronounced nb if whole eyelid swollen, more likely blepharitis (although may have a stye on top of this)

Answer 43

= chronic blepharitis - rosacea - seborrhoeic dermatitis - pregnancy - diabetes mellitus nb most people who get one don't have any reisk factors

Answer 44

clinical diagnosis - EVERT the eyelid to see an internal stye!! REFER IF: - visual disturbance - associated peri-orbital or orbital cellullitis also if suspect it is actually a BCC

Answer 45

DON'T - attempt to puncture / pop the stye - wear eye make up until gone - use contact lenses until gone DO - use warm compresses (5-10 mins 2-4 times a day until resolves) (nb can also use OTC oral analgesias) nb same advice for meibomian cyst PROGNOSIS: SLEF-LIMITING (resolve in 1-2 weeks) if painful external stye, can: - pluck eyelash from infected follicle - incision and drainage only prescribe TOP antibiotic if clinical features of concurrent conjunctivitis (copious muco-purulent discharge) (obvs if associated peri-orbital / orbital cellulitis then give PO/IV Abx for this)

Answer 46

BACKGROUND RETINOPATHY - at least one micro-aneurysm (MA - 'dots and blots') MACULOPATHY - basically anything on the macula (OEDEMA most common, also: ischaemia, haemorrhages) - can get reduced visual acuity PRE-PROLIFERATVE - 'cotton wall spots' (aka soft exudates) - hard exudates (nb in addition to dots and blots) PROLIFERATIVE - new vessel formation (wispy red noodles, often next to ischaemic areas) - get reduced visual acuity! nb maculopathy is seperate to other stages - each other stage can occur with or without maculopathy nb it is actually much more confusion than this with categorisation etc but just learn this!

Answer 47

every year! really important as don't have any symptoms until far down! - and can stop getting worse but is not reversible! - nb if get haemorrhages, these can present as painless floaters! - good glycaemic control - good HTN control - good lipid control (diet + statins) - stop smoking

Answer 48

- cataracts - glaucoma (nb also high risk for hypertensive retinopathy too!)

Answer 49

LASER TREATEMENT - to obliterate new vessel growth - slows progression but does not improve visual acuity INRAVITREAL STEROIDS ANTI-VASCULAR ENDOTHELIAL GROWTH FACTORS -end in mab SURGERY - may need vitrectomy if have an intravitreal bleed

Answer 50

GRADE 1 - increased tortuosity (nb normal in small peripheral vessels) - narrowing (dt deposits) GRADE 2 - silver/copper wiring - AV nipping GRADE 3 - cotton wool spots (ischaemic areas) - hard exudates - flame/splinter bleeds GRADE 4 - papilloedema SYMPTOMS - blurred vision - visual field defects OCCUR LATE in disease!!

Answer 51

Treat primarily by CONTROLLING BP (meds and lifestyle) for retinal edema, sometimes: - laser - intravitreal steroid injection - injeciton of antivascular endothelial growth factor drugs

Answer 52

aka IRITIS inflammation of the iris (coloured part of eye) and anterior chamber HLA-B27 conditions: - ankylosing spondylitis - reactive arthritis - JIA - IBD (both) - bechet's disease (mouth and genital ulcers) - psoriasis/psoriatic arthritis - sarcoidosis - MS also - HIV - TB other: POST EYE SURGERY infection/inflammation

Answer 53

aka IRITIS PAINFUL (deep 'boring', worse with accomodation) and RED eye - PHOTOPHOBIA (hurts when pupuil constricts) - BLURRED VISION nb may also have a headache and feel systemically unwell (also ask about PMHx/joints) need to RULE OUT ACUTE GLAUCOMA (presents very similarly) - obv also all other causes of acute red eye...

Answer 54

ANTERIOR UVEITIS (iritis) 1) conjuctiva: injection most marked around cornea (ie red ring around iris) = PERILIMBAL or CILIARY INJECTION 2) iris: injected 3) pupil: SMALL +/- irregular shape (dt adhesions) 4) cornea: normal 5) anterior chamber: TURGID (CELLS! = HYPERPYON) 6) IOP: normal nb DON'T get hyperpyon in acute glaucoma!

Answer 55

URGENT REFERRAL TO OPTHALM - ANALGESIA - TOP steroids - TOP cycloplegics to dilate pupil and relieve pain/photphobia and prevent formation of adhesions (TOP Atropine, cyclopentolate)

Answer 56

ECTROPION = Eversion of eyelid - itchy / irritated red watery eye, dry eye causes: old age, CN7 palsy, tumour on eyelid, congenital ENTROPION = INversion of eyelid - occular irritation, foreign body sensation, tearing, redness causes: old age, trachoma infection (developing world), congenital

Answer 57

- lubricating eyedrops - skin tape (esp at night) - surgery

Answer 58

assess eye-lashes for TRICHIASIS (misdirection of eyelashes), as this is a common differential MANAGAEMENT - taping eyelid to cheek (esp overnight - botox for eyelid muscles - surgery to correct!

Answer 59

inflammation of eyelids (+/- super-imposed bacterial infection) Chronic condition: symptoms get better + worse - red/swollen eyelids - crusty/gritty eyelids (esp when wake up) - eyelashes falling out - watery eyes - feeling of something in your eye Mx = Good eye hygiene - warm, hot compresses - massage - cleaning lids with cotton buds - clean baby shampoo also artificial tears nb can give course of steroid or antibiotic eyedrops if really bad, but rarely! nb also tell peopl not to wear eye maker up, contact lenses etc when it's bad!

Answer 60

EPISCERITIS = inflammation of superficial episcleral layer of eye - affects SUPERFICIAL episcleral vascular plexus SCLERITIS = inflammation of sclera of eye - affects DEEP episcleral (aka scleral) vascular plexus give PHENYLEPHERINE eye drops: - wait 5 mins: - if EPIscleritis, redness will BLANCH - if scleritis, will NOT blanch!

Answer 61

EPISCLERITIS EPISCLERITIS 1) mild DISCOMFORT, may be mild photophobia and watering 2) NO pain on eye movement 3) red eye (may be a patch or diffuse - no blue) 4) no visual change 5) normally idiopathic (can be associated with IBD) SCLERITIS 1) deep, dull ACHE (at night / headache) + tender to touch, photophobia 2) pain on eye movement (sclera attached to muscles) 3) BLUISH/purple hue to sclera plus redness (that does NOT blanch w epinepherine drops) 4) may be visual change! 5) 30-50% have rheum disease (arthritis and weird vasculitises) nb both can be unilateral or bilateral

Answer 62

Episcleritis - self-limiting so reassure - give topical NSAIDs (diclofenac /ketorolac) (+/- artificial tears) Scleritis - urgent opthalm referral (risk of sclera thinning and globe perforation)

Answer 63

PAINFUL - temporal arteritis - migraine PAINLESS - retinal artery embolism - retinal vein thrombosis - spontaneous vitreous haemorrhage (floaters) - retinal detachment - posterior cerebral artery stroke - optic neuritis (usually MS)

Answer 64

Aka swinging light test Tells you that either the optic nerve AND/OR retina is damaged Get paradoxical dilation of abnormal eye when put light on it after putting light on normal eye **check that this is right!!

Answer 65

Inflammation of optic nerve - MS - also idiopathic, post URTI, drugs/toxins Core symp 1) REDUCED vision (varying) 2) PAIN on eye MOVEMENT 3) impaired COLOUR vision (For latter, show red pen lid, get cover eye and compare between normal and abnormal eye - will be duller colour in abnormal) Exam - red desaturation - RAPD - swollen optic disc (fundoscopy) Do MRI brain if suspect MS (Also do ESR and CRP) Mx - steroids (IV) - urgent referral to opthalm

Answer 66

CENTRAL RETINAL ARTERY OCCLUSION 1) norm EMBOLI from: 2) carotid plaques, rarely sickle cell or vasculitis 3) sudden, painless COMPLETE loss of vision unilaterally 4) RAPD! (normally) 5) pale retina + bright red macula (aka cherry red spot) 6) eye drops to lower IOP, massage eye + call opthalm asap CENTRAL RETINAL VEIN OCCLUSION 1) norm THROMBUS from: 2) IHD, HTN, high cholesterol (+other norm stroke RFs) 3) sudden, painless BLURRED -> COMPLETE loss of vision unilaterally 4) Occasionally RAPD (but rarely) 5) optic disk oedema and red dots (haemorrhages) all over macula 6) aspirin + call opthalm asap

Answer 67

ANTERIOR - mild - source of bleeding visible in 95% of cases - almost always from nasal septum at 'little's area" where kiesselbach's plexus forms POSTERIOR - larger volume and risk of airway compromise! - occurs commonly in elderly - source if from deeper structures of nose

Answer 68

commonest causes = trauma (incl nosepicking) = foreign bodies - anticoags - antiplatelets - cocaine - von willebrands disease - granulomatosis with polyangitis (wegners) HTN also increases risk!!! nb also obviously more likely to have in haemophilias and other bleeding conditions (incl alcohol excess) - but Von Wille most common and typical!

Answer 69

ANTERIOR = blood running from ONE nostril POSTERIOR = blood running into THROAT AND from BOTH nostrils - FBC - Group + save (if large) - clotting ^nb these are to consider - don't always do! look for antiplatelets and anticoags - stop (and reverse latter) if relevant age under 2 - more likely to be 1st presentation of haemophillia or leukaemia ALWAYS REFER IF UNDER 2!!!

Answer 70

if UNstable: A-E resus if STABLE: 1st) pinch SOf bit of nose for 15 MIN 2nd) lidocaine + phenylepherine gauze OR spray 3rd) silver nitrate cauterise (ONLY if can visualise where bleeding from! - never do both sides of septum!) 4th) anterior packing! 5th) call ENT (they can do ligation or posterior packing with foley catheter)

Answer 71

UN-DISPLACED - no treatment required DISPLACED - reduction under GA/LA with post-op splint (within 2 weeks - complete setting occurs at 3 wks!) - septoplasty (if a lot of post-traumatic deformity, do primary septal reconstruction) BOTH - sleep with head elevated - apply ice (for 12hrs post-op)

Answer 72

nasal septal haematoma haematoma between the septal cartilage and the overlying perichondrium may be precipitated by relatively MINOR trauma!! main symp = SENSATION of NASAL OBSTRUCTION also: - pain - rhinorrhoea OE: classically a bilateral, red swelling arising from the nasal septum how to differentiate between deviated nasal septum: - gently probe the swelling - haematomas = boggy - septums = firm

Answer 73

- surgical drainage - INTRAVENOUS antibiotics if untreated: irreversible septal necrosis may develop within 3-4 days nb if untreated may result in a 'saddle-nose' deformity

Answer 74

- surgery - trauma - foreign bodies - piercings - nasal sprays - cocaine - malignancy (rodent ulcer) - chronic granulomatous disease (eg TB, sarcoidosis)

Answer 75

Perforations irritate! - WHISTLE noise - Crust - Epistaxis

Answer 76

- Rhinoplasty to close - Saline douche for crusts - Silastic buttons to occlude hole

Answer 77

Ethmoid (basal skull) fracture disrupting dura and arachnoid results in CSF leak!! Nasal discharge test +ve for glucose (bed side dipstick) nb can also send CSF sample to lab – B2 (tau) transferrin (gold standard ∆)

Answer 78

CT head! Conservative Mx – bed rest, self resolves 7-10 d Cover with: - Abx - Pneumococcal vaccine

Answer 79

Most self-inserted by child 2.5% cocaine spray (avoid in child) can shrink mucosa to allow removal/suction Remove foreign body with forceps carefully BATTERIES require URGENT removal

Answer 80

- sneezing - bilateral nasal obstruction - clear nasal discharge - post-nasal drip - nasal pruritus atopic conditions (eczema, asthma, allergies)

Answer 81

ALLERGEN AVOIDANCE (easier said than done!) 1st) oral or intranasal antihistamines if persistent mod-severe symptoms (or failure of antighistamines): - short course intra-nasal corticosteroids - short course topical nasal decongestants, eg oxymetazoline (see below!) nb topical nasal decongestants (eg oxymetazoline) should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal nb a short course of oral corticosteroids are occasionally needed to cover important life events

Answer 82

- strep pneumoniae - haemophilus influenza - rhinovirus - nasal obstruction (e.g. septal deviation or nasal polyps) - recent local infection (e.g. rhinitis, dental extraction, URTI) - swimming/diving - smoking nb: Acute sinusitis usually follows a common cold, and is defined as an increase in symptoms after 5 days, or persistence of symptoms beyond 10 days, but less than 12 weeks.

Answer 83

FACIAL pain - typically frontal pressure pain which is WORSE on BENDING FORWARD - nasal discharge (norm thick and purulent) - nasal obstruction (feeling)

Answer 84

ANALGESIA nb intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited INTRANASAL STEROIDS - may be considered if the symptoms have been present for more than 10 days ORAL ABX - norm NOT required - can give if SEVERE presentations (ie systemiacally unwell) nb 'double-sickening' may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection

Answer 85

lasts AT LEAST 12 WEEKS! 1) FACIAL PAIN (frontal pressure pain, worse on bending forward) 2) NASAL DISCHARGE (usually clear if allergic or vasomotor, thicker purulent discharge suggests secondary infection) 3) NASAL OBSTRUCITON eg mouth breathing 4) POST-NASAL DRIP - may produce a chronic cough

Answer 86

avoid allergen - intranasal corticosteroids - nasal irrigation with saline solution nb irrigation not proven benefit for acute sinusitis but usefuyl for chronic

Answer 87

- unilateral symptoms - persistent symptoms despite compliance with 3 months of treatment - epistaxis if get any of these - consider ENT referral

Answer 88

- male - adults - asthma - aspirin sensitivity - infective sinusitis nb Nasal polyps are NOT associated with allergy - CF - kartagener syndrome - churg-strauss syndrome

Answer 89

1) Nasal obstruction – mouth breathing, snoring 2) Rhinorrhoea – watery, post-nasal drainage 3) Sneezing 4) Poor sense of taste and smell

Answer 90

TUMOUR - UNILATERAL discharge/symptoms - EPISTAXIS Nasal polyps tend to be bilateral. With unilateral lesions, suspect a tumour (and in children, rule out an encephalocele)

Answer 91

children with nasal polyps always screen for cystic fibrosis!!

Answer 92

use nasal speculum to examine TOPICAL (ie nasal) steroids! refer if: - red flag symptoms - significant nasal obstruction - poor response to 3 months of nasal steroids (check technique) nb ENT surgeons may presvribe oral steroids if bad nb pts with persistent symptoms despite optimal medical management may be referred for surgery!

Answer 93

disorder of pilosebaceous follicles of face and upper trunk → at puberty androgens ↑sebum production from sebaceous glands → blocks glands → comedones may be open (blackheads) or closed (white heads) → papules, pustules, nodules - comedones - papules - pustules - face - neck - back clinical diagnosis

Answer 94

- teenagers - M>F cushings - disease or anabolic steroid use!

Answer 95

MILD - facial comedones MODERATE + inflammatory lesions, face +/- torso SEVERE + nodules + cysts + scars

Answer 96

MILD - TOP Benzoyl peroxide - TOP Azelaic acid (6 months) ``` MODERATE - TOP Clindamycin - TOP retinoids (eg tretinoin or adapalene) - PO doxycycline or clarithromycin (- can also consider COCP if severe!) ``` SEVERE - PO Isoretinoin for 20wks so: - mild = TOP acids - mod = TOP retionoid / TOP/PO abx - severe = PO retinoid nb low-strength benzoyl peroxide are OTC, others prescribed

Answer 97

- teratogenic - depression + suicide risk! nb topical retinoids are also slightly teratogenic (but not as much) so shouldn't be used in people trying for baby or currently pregnant!

Answer 98

``` 16+18 = cervical cancer 6+11 = warts ``` nb HPV enters basal epithelia of genital skin via micro abrasions during sexual contact → genital warts (benign growths) nb cervical screening covered in GOSH notes

Answer 99

- Multiple sexual partners - DM - immunocomp - pregn - COCP

Answer 100

Median incubation = 3 months Resolves in 3 months with treatment (Median detectability in genital skin = 1 year) High recurrence! Warts are most contagious when visible Grow rapidly during pregnancy → regress after birth

Answer 101

soft CAULIFLOWER-LIKE growths of varying size. (Less commonly, they are flat, plaque-like or pigmented) colour: whitish to flesh-coloured to hyperpigmented to erythematous norm <10 mm in diameter (but may coalesce into large plaques, esp if immunosuppressed or DM) - local irritation or discomfort - may get superficial dysparaunia - may get dysurea if in urethra - maybleed/be painful if catch on clothing! can get INGUINAL LYMPHADENOPATHY! need to examine using speculum for women! nb can also get: Periungual warts are common warts around the nails that can be painful and disturb nail growth — nail biting is a risk factor

Answer 102

other STIs!! - chlamydia - gonorrhoea - syphillis - HIV

Answer 103

1) PODOPHYLLOTOXIN SOLUTION - not in preg or for anal warts - nb also: Imiquimod or Sinecatechins cream instead 2) CRYOTHERAPY - or excision or electrocautery IN PREGNANCY: - Warts may appear, recur or persist in pregnancy - Treatment options limited - Warts resolve after delivery – vaginal is typical nb in about 30% of people, warts disappear spontaneously within 6 months without any treatment! nb normn managed in sexual health clinic or by specialist GP

Answer 104

wear condoms!! (reduces risk, risk not zero!) stop smoking (smoking increases risk of recurrence!)

Answer 105

nb look the same as anogenital warts or slightly different 1) topical salicylic acid 2) cryotherapy nb don't have to treat - most go away within months-2 years refer to derm: - if on face - if diagnostic uncertainty

Answer 106

- UV light exposure (usually arise on head, face & neck) - Radiotherapy - Fair skin (increased risk in Caucasians) Arise on sun exposed areas (head, face, neck) Early lesions are small, PEARLY & have edges w/ TELANGIECTASIA

Answer 107

SUPERFICIAL - Flat, well demarcated lesion +/- bleeding/weeping - Typically >20mm on presentation - Central clearing w/ thread like border - Multiple erythematous lesions w/ equal distribution on face/arms/trunk NODULAR: - Solitary, shiny, red nodule (usually on face) - Cystic & pearly central appearance w/ large telangiectasia MORPHOEIC - Thickened Yellowish plaque with irregular borders - Usually on mid-facial site Present late, and are quite aggressive PIGMENTED - Brown, black, or blueish lesions - Present on people w/ darker skin - May resemble malignant melanoma nb don't think I need to know this much depth!! - just know classical appearance!

Answer 108

always examine nearby LYMPH NODES refer for EXCISIONAL BIOPSY if suspect local invasion (eg of nerves/glands) or any bone involvement suspectd = CONSIDER CT or MRI

Answer 109

higer risk = any immunocompromise = under 24years old = tumour >1cm diameter = tumour adjacent to orifices (incl eye!) nb refer all! - these are just the ones at highest risk and should definitely be seen in 2 weeks!

Answer 110

SURGERY - wide local excision (BEST!) - curettage (not if large or face) NON-SURGICAL - imiquimod cream (if small + superficial) - phototherapy (if superficial, have good cosmetic result!)) - radiotherapy (norm for recurrence/incomplete resection) nb prognosis is good (<0.5% metastasise, risk greater if >3cm in diameter) do have increased risk of another one, SCC, melanoma - so advice re sun protection etc nb would only do radiotherapy once on each site (as acts as it's own risk factor)

Answer 111

NODULAR = molluscum contagiosum ``` SUPERFICIAL = SCC = discoid eczema = Bowen's disease = Psoriasis ``` MORPHOEIC = scar tissue = scleroderma PIGMENTED = malignant melanoma nb Discoid eczema = scattered, well-defined, coin-shaped and coin-sized plaques of eczema (aka nummular dermatitis) nb Bowen's disease (aka Intraepidermal SCC) = one or more irregular scaly plaques of up to several centimetres in diameter (often an orange-red colour but may be brown)

Answer 112

- bowen's disease (squamous carcinoma in-situ) - actinic (or solar) keratosis SCC = an irregular keratinous nodule or a firm erythematous plaque, and frequently ulcerates LYMPHADENOPATHY may indicate metastases

Answer 113

- sun exposure - white! - HPV - chemical exposure (arsenic, soot, tar) - radiotherapy nb having a pre-malignant condition (bowens / actinic keratosis) also increases your risk!

Answer 114

biopsy (norm just do at the time of excision!) EXCISION = most common mx - currettage (only if <1cm) - radiotherapy (for inoperable or recurrent SCCs) - TOP imiquimod cream (for actinic keratosis) - photodynamic therapy (for actinic keratosis and bowens/in-situ) REDUCE SUN EXPOSURE!

Answer 115

5% increased risk: - near orifices (esp lip/ear) - >2cm diameter - depth >4mm - poor differentiation - recurrence

Answer 116

- bowens (carcinoma in-situ) - actinic (solar) keratosis - BCC - Malignant Melanoma (especially amelanotic) - Keratoacanthoma - Seborrheic keratosis (or warts) nb keranthoma: skin lesion that erupts in sun-damaged skin (like a little volcano). It grows for a few months; then shrinks and self resolves (norm managed surgically as hard to differentiate clinically from SCC) nb Seborrhoeic keratosis are harmless warty spots, appear more with age, some people have hundreds

Answer 117

Lots of Naevi!! - Individual w/ > 100 common naevi or > 2 atypical naevi has a 5-20 fold increased risk of melanoma - white - female (although male have higher mortality) - sun exposure

Answer 118

``` A Asymmetry B Border irregularity C Colour variation (>2 colours) D Diameter over 6 mm E Evolving (enlarging, changing) ``` GLASGOW 7-POINT CHECKLIST Major features - Change in size - Irregular shape - Irregular colour Minor features - Diameter >7 mm - Inflammation - Oozing - Change in sensation

Answer 119

SUPERFICIAL MELANOMA (70%) - Large flat, irregular pigmented lesion - Grows laterally before vertical invasion develops LENTIGO MALIGNA - Patch of lentigo maligna develops a papule or nodule NODULAR MELANOMA - most aggressive - Rapidly growing pigmented nodule – bleeds or ulcerates - Very rarely amelanotic (non-pigmented) - Metastasise early – poor prognosis ACRAL LENTIGINOUS MELANOMA - Pigmented lesions on palm, sole or under nail (late) SUBUNGAL - nailbed nb all of these can be amelanotic

Answer 120

examine for LYMPHADENOPATHY (means likely stage 3 or 4) 1) biopsy and histopathology 2) sentinel lymph node biopsy (if microscopic disease detected = stage 3 or 4) 3) CT staging (if stage 2c or above)

Answer 121

- BRESLOW thickness (to nearest 0.1mm) - if ulceration is present or not (poorer prognosis if is) (nb other things on hisotlogy report too!) ``` STAGES 0 = in-situ 1 = <2mm thick 2 = >2mm thick (or >1mm +ulceration) 3 = local lymph node spread 4 = distant mets ``` nb have stage 1abc, 2abc etc too but don't bother learning!

Answer 122

BRAFV600 in 50% of melanomas! do genetic testing to see if have

Answer 123

EXCISION 0 = 0.5mm margin 1 = 1cm margin 2 = 2cm margin stage 3 = excision PLUS lymphadenectomy!! (+/- treamtnet for stage 4 - do a CT scan! NEED follow up regularly for up to 5 years for all stages (except 0)

Answer 124

basically TARGETED and/or IMMUNOTHERAPY incl targeted at BRAF gene! Immunotherapy: interleukin-2, interferon alfa 2b BRAF inhibitors: dabrafenib and vemurafenib MEK inhibitors: trametinib Combination BRAF and MEK inhibitors: dabrafenib C-KIT inhibitors: imatinib, nilotinib CTLA-4 antagonist: ipilimumab PD-1 blocking antibodies: nivolumab, pembrolizumab

Answer 125

- venous - arterial - neuropathic/diabetic

Answer 126

``` VENOUS = varicose veins = previous DVT = HTN - Obesity - increasing age - immobility ``` ``` ARTERIAL = IHD = PVD = HTN = Diabetes = CKD = RA - smoking - obesity ``` NEUROPATHIC = diabetes - poor foot care / badly fitting shoes - smoking

Answer 127

VENOUS 1) norm medial side of ankle 2) typically shallow with irregular sloping edges (typically wet w heavy exudate) 3) relatively painless (unless infected) 4) - aching, swollen legs that feel more comfortable when elevated - varicose veins - mottled brown/black staining and/or dry, itchy and reddened skin (venous eczema) - lipodermatosclerosis (hardened lower leg) - swelling +/- lymphoededma ARTERIAL 1) feet, heels or toes 2) deep with 'punched out' edge (typically dry and scabbed) 3) Frequently painful (esp at night in bed or whenlegs are at rest /elevated, relieved by standing) 4) - cold, white or bluish feet - difficulty palpating pulses - may be intermmitenet claudication on walking NEUROPATHIC ULCER 1) heels, tips of toes, between toes or any pressure points 2) similar to arterial but may be surrounded by thickened skin 3) not normally painful (unless infected) 4) - poor foot care - sensory loss on foot

Answer 128

Ankle Brachial Pressure Index (ABPI) The normal value of 0.92 to 1.3. If the ABPI is less than 0.9, there is likely to be arterial disease. Levels of less than 0.5 indicate severe arterial disease.

Answer 129

STOP SMOKING (really slows healing!) better control of BLOOD SUGARS (if diabetic) wound dressing for ALL - different types available! VENOUS = COMPRESSION BANDAGE - but ONLY if good arterial supply (do ABPI before applying!)

Answer 130

refer arterial ulcers to VASCULAR - do ABPI first! consider foot x-ray and/or MRI if neuropathic ulcer that is deep! - as high chance of osteomyelitis (MRI best!! - changes take a while to see on x-ray!)

Answer 131

INFECTION - erythema - new pain - increased swelling - yellow surface crust or green/yellow pus - fever ^nb this is norm cellulitis - but can progress to osteomyleitis (esp for neuropathic!) ^norm use FLUCLOX but can swab wound (only if clinically suspect infection!) and adjust abx use! NEUROPATHIC ULCERS - charcots foot - ambutation (can happen with other ulcers but rare) nb don't swab ulcers unless signs of infection!!!

Answer 132

aka ACTINIC KERATOSIS may be solitary but often multiple keratoses appearance varies: - flat or thickened papule or plaque - White or yellow; scaly, warty or horny surface - Skin coloured, red or pigmented - Tender or asymptomatic very common on sites repeatedly exposed to the sun rare for a solitary actinic keratosis to evolve to SCC - but risk of SCC occurring at some stage in someone with > 10 is about 10 to 15% A tender, thickened, ulcerated or enlarging actinic keratosis is suspicious of SCC nb lots of different management options with cytotoxic cream, cryotherapy, excision etc!

Answer 133

firm, smooth, hard growth due to spontaneous scar formation - Raised, Irregular shape, - Rubbery texture - Red initially → brown/pale with age may be uncomfortable or itchy extend well beyond the original wound can arise soon after an injury, or develop months later higher risk - FHx - darker skin

Answer 134

a CYST typically associated with a tendon sheath or joint capsule of the HAND (nb different to ganlgion of nerve cell bodies in neurology!) The origin of a ganglion cyst is degeneration of the mucoid connective tissue of a joint - most often affect scapholunate joint of dorsal wrist - young-middle aged adults - F>M - unilocular or multilocular firm swelling 2–4 cm in diameter that transilluminates nb can be painful (lies adjacent to nerve) nb these are self-limiting (typically disappear in a few months!)

Answer 135

HIV +ve patients (esp MSM) any immunosuppression (incl post-transplant patients etc) - nb can also get in some older diabetics Caused by herpes virus 8 (HHV8) which is often sexually transmitted but doesn't cause lesions unless immunocompromised (or very unlucky!) nb is not actually a sarcoma! - is a disease of the endothelial cells of blood vessels + lymphatic system (multicentric vascular hyperplasia)

Answer 136

- red to purplish macules, papules and nodules - anywhere on the skin or mucous membranes lining the mouth, nose, and throat; lymph nodes; or other organs. - Initially, lesions are small and painless, but they can ulcerate and become painful Kaposi sarcoma lesions can also occur internally and cause symptoms such as: - Discomfort with swallowing - Bleeding - Haematemesis - Haematochezia - Melaena - Bowel obstruction - Shortness of breath - Swollen legs nb management: treat underlying immunosppression (eg HAART or reducing/changing immunosuppresive medications) - can also do localised treatment (eg cryotherapy, radiotherapy or excision but lesions almost always reoccur if still immunosuppressed!) - can also give systemic chemo or immunotherapy

Answer 137

COUGH IMPULSE - inguinal hernia (above + medial to pubic tubercle) - femoral hernia (below + lateral to pubic tubercle) NO COUGH IMPULSE - compressible = saphina varix - expansile = femoral artery aneurysm - transilluminates = hydrocele of cord - hard = lymph node - soft = lipoma if IVDU = consider GROIN ABSCESS! nb enlarged lymph node could be reactive (infection) or malignant (lymphoma or met) nb with saphina varix there's norm varicose veins on leg as well!

Answer 138

cervical chain lymph nodes! learn where these are again!!!

Answer 139

BRACHIAL CYST - unnoticed until inflammed during URTI (are painless) CAROTID BODY TUMOURS - pulsatile THYROID NODULES - check TFTs - systemic hypo/hyperthyroid (norm latter) symptoms LARYNGOCELE - hoarseness (+ may inflate and deflate while talking/vasalva) plus LYMPH NODES!! - look for red flag symptoms!

Answer 140

THYROGLOSSAL CYST - moves with swallow AND tongue protrusion ^nb this makes sense as 'glossal' is attached to the tongue! THYROID ISTHMUS NODULE - moves on swallow ONLY ^makes sense as thyroid cartillage (attached to thyroid) is what moves when swallow!) DERMOID CYST - doesn't move with any actions! ^as only attached to skin!

Answer 141

CYSTIC HYGROMA - transilluminates - sac full of lymph fluid VIRCHOWS NODE - internal organ malignancy (norm stomach Ca) CERVICAL RIBS - hard lump - may have sx of arm pain/parasthesia with activity (called thoracic outlet syndrome) plus LYMPH NODES!! - look for red flag symptoms! nb cystic hygromas can be diagnosed antenatally if large, may complicate delivery

Answer 142

ULTRASOUND!!! (for all except cervical rib!) thyroid nodule - TFTs - final needle aspirate (FNA) lymph node - core biopsy consider referral to head + neck surgeons - cystic hygroma - laryngocele - thyroglossal cyst - dermoid cyst

Answer 143

- Hard and fixed lump - otalgia - dysphagia - stridor - hoarse voice - Epistaxis - unilateral nasal congestion - Cranial nerve palsies - Unexplained weight loss - night sweats - fever or rigors

Answer 144

strabismus eso = looking medial (aka convergent) exo = looking lateral (aka divergent) hypo = looking down hyper = looking up

Answer 145

CONCOMITANT (aka non-paralytic) - due to imbalance in extraocular muscles (nerves and movements grossly normal) - norm congenital PARALYTIC - norm acquired damage to cranial nerves (or extraocular muscles) - almost always acquired - more worrying - get DIPOLOPIA nb see paeds flashcard for info on non-paralytic (concomitant) squint

Answer 146

CRANIAL NERVE THREE = occulomotor = all expect lateral rectus + superior oblique - 'down and out pupil' - also get ptosis +/- DILATED pupil (called pupil sparing if pupil not dilated!) ``` CRANIAL NERVE FOUR = trochlear = superior oblique muscle (SO4) - get vertical diplopia - head tilt (as everything looks tilted to them) ``` CRANIAL NERVE SIX = abducens = lateral rectus muscle (LR6) - horizontal diplopia (most pronounced when looking laterally towards muscle affected)

Answer 147

PUPIL-SPARING = ischaemic microvascular disease (HTN, DM etc) = idopathic PUPIL-INVOLVING = berry aneurysm - tumour - trauma nb you can get temporary 3rd nerve palsy as the result of a migraine! (remember called pupil sparing if pupil not dilated!)

Answer 148

CRANIAL NERVE 4 - trauma - vasculopathy (norm HTN, DM) - demyelinating disease (eg MS) ``` CRANIAL NERVE SIX = raised ICP (infection/inflamm or SOL) - vasculopathy (norm HTN, DM) - trauma - idiopathic ``` nb raised ICP is NOT most common cause (that's vasculopathy or trauma - but is the most serious one!) nb cranial nerve 6 can also go due to post-viral infections in kids, giant cell arteritis and MS

Answer 149

acute otitis media: 4 days acute sore throat/acute pharyngitis/acute tonsillitis: 1 week common cold: 1.5 weeks acute rhinosinusitis: 2.5 weeks acute cough/acute bronchitis: 3 weeks

Answer 150

PHARYNGITIS - typically viral NON-EXUDATIVE TONSILITIS - adenovirus - enterovirus - rhinovirus - RSV EXUDATIVE - group A B-haemolytic strep - EBV nb this is why bacterial tonsilitis and EBV so often confused as they can both have exudate!

Answer 151

VIRAL TONSILITIS - Pre-coryzal Sx (nasal discharge + block) - Fever - Cough (+ wheeze if asthmatic) - Painful throat (2/7) - Odynophagia - Earache YOUNG KIDS / INFANTS: - Poor feeding (infant – noses blocked → obstructs breathing) - Febrile convulsions O/E: - Enlarged + inflamed tonsils + uvula nb can also get an acute exacerbation of asthma

Answer 152

CENTOR 1) Fever >38deg 2) tonsillar exudate 3) cough ABSENT 4) cervial lymph node tenderness / swelling must have at least THREE to give ABx! (still only 30-50% of these are bacterial) should ALWAYS do a throat swab before givibng Abx! (this done in practice?) nb if pt deemed at risk of developing complications: PRESCRIBE IMMEDIATELY - systemically very unwell - signs of complication (eg quinsy, intracranial complications) - pre-existing co-morbidities (significant lung, heart, liver, immunosuppression, CF, premature infants)

Answer 153

- fluids - rest - analgesia (paracetamol + nsaids) for ALL IF BACTERIAL 1st) PEN V (phenoxymethylpenicillin) 2nd) erythromycin (if pen-allergic) NEVER: amoxicillin!!! (causes rash if EBV) TONSILLECTOMY IF: 7 episodes in the past year, 5 episodes per year in the past 2 years or 3 episodes per year in the past 3 years, and all infections should be culture confirmed group A strep

Answer 154

``` SUPPURATIVE = peri-tonsiluar abscess (quinsy) = otitis media - meningitis - brain abscess ``` NON-SUPPURATIVE SCARLET FEVER - rash appears 1-2 days after sore throat starts) ACUTE RHEUMATIC FEVER - several weeks after sore throat POSTSTREPTOCOCCAL GLOMERULONEPHRITIS - 1-2 weeks post strep throat nb giving Abx for strep throat doesn't decrease the incidence of glomerulonephritis - but it does decrease incidence of all the others!

Answer 155

- sandpaper papular rash - strawberry tongue - sore throat often confused with kawasaki! - look for fever LONGER THAN 5 days, conjunctivia involvement and hand involvement ?and some other stuff!

Answer 156

presents SEVERAL WEEKS following the initial symptoms - arthritis - cardiac inflammation - CNS involvement - subcutaneous nodules - fever - rash nb Rheumatic fever historically was a common cause of valvular heart disease (norm MITRAL regur or stenosis), however incidence has significantly reduced with the introduction of abx therapy

Answer 157

presents 1-2 weeks following onset of pharyngitis - 'cola-coloured urine' (blood + protein - nephritic syndrome!) - periorbital edema - malaise - decreased appetite

Answer 158

- throbbing unilateral throat pain (severe!) - trismus (difficulty opening mouth - dysphagia - stridor - coarse voice - fever - CONTRALATERAL deviation of uvula - decreased neck mobility ^nb they may have a vague and non-specific Hx! Mx - urgent ENT review - surgical drainage under LA - antibiotics! (broad) nb can do lateral neck x-ray to visualise

Answer 159

haemophilus influenza - 1-6 years high risk = unvaccinated children! (eg traveller community) is very fast onset!! - difficulty breahting (-> resp distress + increased HR) - inspiratory AND expiratory soft stridor - painful throat (can't speak or swallow!) - drooling saliva - HIGH temp - very tioxic looking! Child sitting immobile, upright with mouth open (trying to optimise airway) nb normally DON'T have a cough (one way to differentiate from croup!) nb george washington died of this and/or the blood letting the drs did to attempt to treat it...

Answer 160

don't examnine thir mouth unless prepared to intubate! - also don't agitate the child! blood cultures only AFTER safely stabilised airway!! can do lateral x-ray (get thumb print) - aslthough often don't do this or do Ppost-management!

Answer 161

1) INTUBATE (immediately) w/ general anaesthetic – often unsuccessful - TRACHEOSTOMY (if intubation fails) – life saving! Often managed in ICU 2) Take Blood cultures + give IV Abx AFTER airway stabilised - IV CEFUROXIME or CEFOTAXIME (until 3-5 d post tracheal tube removal) give RIFAMPICIN prophylactically to all household members!

Answer 162

- foreign body aspiration - tonsilar abscess (quinsy) - croup - anaphylaxis - laryngomalacia

Answer 163

- resp arrest -> death - abscess - sepsis - meningitis - pneumothorax

Answer 164

- neck lump - hoarseness - persistent sore throat - persistent mouth ulcer nb dysphagia is more commonly oesophageal Ca

Answer 165

2WW = unexplained ULCERATION in the oral cavity lasting for more than THREE WEEKS OR = a persistent and unexplained lump in the neck URGENT (but not 2ww) - a lump on the lip or in the oral cavity OR - a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia nb there is no lower age limit!! (oral cancers relatively common in younger ages!)

Answer 166

people aged 45 and over AND - persistent unexplained hoarseness OR - an unexplained lump in the neck

Answer 167

norm idiopathic (can be from compression: cholesteatoma or acoustic neroma) CN 5 = trigeminal U/L shock-like pain paroxysms across CN5 distribution - Abrupt in onset and termination - Limited to one or more division of trigeminal Provoked by: light touch, washing, shaving, smoking, talking, brushing nb Nasolabial fold may act as trigger area a/w numbness and tingling nb 5% of peiople have bilateral symptoms

Answer 168

carbamazepine = 1st line RED FLAGS - sensory changes - deafness or other ear problems - PMHx of skin or oral lesions that could spread perineurally - pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally - optic neuritis - FHx of MS - age of onset BELOW 40 years! ^refer to neurology is any of these features!

Answer 169

- voice overuse - smoking - laryngeal cancer - lung cancer - viral illness - hypothyroidism - gastro-oesophageal reflux consider doing CXR (to exclude apical lung lesions!)

Answer 170

Globus sensation is the feeling of having a lump in the throat when in fact there is nothing there notice most when swallowing own saliva (can actually be improved when swallowing food) need to make sure that this is not an organic cause of dysphagia!! nb can be managed with reassurance, SALT pysio, CBT and managing reflux + postnasal drip which make worse