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

Question 1

Q

OTITIS EXTERNA

what is it?
time definition of acute and chronic?
group of organisms more likely to cause acute?
group of organisms more likely to cause chronic?

Answer

A

inflammation of external ear canal

Acute = < 3 weeks (aka “Swimmer’s” Ear)
- norm bacterial (norm staph aureus)

Chronic = >3 months
- norm fungal (norm aspergillus)

Question 2

Q

OTITIS EXTERNA

age most affected?
lifestyle risk factors? 3
medical conditions that are risk factors? 3

Answer

A

age (peaks between 7-12 years)

Moisture (swimming)
Trauma (ear clearance w finger/cotton bud)
Hearing aids
Wax build up
DM
Immunocompromised

Question 3

Q

OTITIS EXTERNA

two main initial symptoms? 2
main finding on examination? 1
late severe signs/symptoms? 3

Answer

A

MAIN SYMPTOMS

pruritic/itchy ear
otalgia (esp on movement of tragus)

O/E
-erythema AND oedema of ear canal + ear
(Also mobile tympanic membrane)

LATE SIGNS

pre-auricular lymphadenopathy
discharge
hearing loss

nb can also get a fever but not common

Question 4

Q

OTITIS EXTERNA

possible investigation? 1 (when do?)
ear hygiene advice?
medication treatment options? 3
additional medication to help with symptoms? 1

Answer

A

Can do EAR SWAB (rarely useful unless Sx are persistent/recurrent)

Olive oil for ear wax
if swollen/narrow ear canal: can put wick/gauze soaked in sofradex
Avoid cotton buds!

Mild = TOP Acetic acid spray 2% Mod = TOP Abx ± Steroids 
Nb TOP Abx include neomycin and clioquinol (then TOP steroids have same names as PO/IV ones)

advice SIMPLE ANALGESIA (paracetamol/nsaids)

Nb most resolve within a few days!

Question 5

Q

OTITIS EXTERNA

- differential diagnosis? (3 common, 3 rarer)

Answer

A

= contact eczema / dermatitis
= impacted ear wax
- foreign body

= perforated otitis media (or chronic secretory OM)
- cholesteatoma

malignancy (if unresponsive to Mx)

Question 6

Q

OTITIS EXTERNA

most common complications? 3
rare, but serious type of otitis externa? 1

Answer

A

hearing loss
narrowed ear canal
abscess

NECROTIZING (MALIGNANT) OTITIS EXTERNA
=immunocompromised its (90% are pseudomonas)
-severe pain
-exudate + oedema
-micro-abscesses
-headache +/- facial nerve palsy

Can spread to bone causing osteomyelitis + death

Need urgent admission and ENT referral

Question 7

Q

IMPACTED EAR WAX:

most common symptom? 1
other symptoms? 4

Answer

A

hearing loss = MOST COMMON

blocked ears / feeling of fullness
ear discomfort / earache
tinnitus
itchiness

nb ?vertigo (although that not confirmed!)
nb can also get cough (dt stimulation of vagus nerve)

Question 8

Q

IMPACTED EAR WAX:

main exam to do?
main DDx? 4

Answer

A

look with otoscope (if impacted, won’t see ear drum)

DDx

otitis externa (esp if inflammation of external ear)
foreign bodies (esp in children)
polyp of ear canal
osteoma of ear canal

nb can also get rare thing called: keratosis obturans (see pearly white plug of keratin)

Question 9

Q

EAR WAX:

when should it be removed? 5
1st line management?
2nd line management?
3rd line management?

Answer

A

If earwax is totally occluding the ear canal AND any of the following are present:

Hearing loss
Earache
Tinnitus
Vertigo
Cough suspected to be due to earwax

nb if suspected perforated ear drom, don’t do these things!

1ST LINE
- olive oil or sodium bicarb ear drops for a week

2ND LINE
- ear irrigation

can return and have more drops then more irrigati9on etc but if really can’t clear:

3RD LINE
- refer to ENT for manual removal

nb if recurrent, can have regiular drops and/or irrigation etc (basically whatever works!

always safety net for infection!!

Question 10

Q

DEAFNESS

causes of conductive? (4 common, 4 rarer)
causes of sensorineural? (3 common, 4 rarer)

Answer

A

CONDUCTIVE

= ear wax
= otitis externa

= otitis media
= glue ear

otosclerosis
cholesteatoma (see other flashcard)
foreign body
perforated tympanic mebrane (eg from trauma)

SENSORINEURAL

= presbycusis
= noise induced hearing loss (NIHL) (60% also have tinnitus)

= congenital (eg Alports)

meniere’s disease
acoustic neuroma
drug ototoxicity
damage to brain (eg meningitis, multiple sclerosis, infarct)

Question 11

Q

OTOSCLEROSIS

what is it?
main risk factor?
age of onset?
two main symptoms?

Answer

A

get replacement of normal bone by vascular spongy bone.

Autosomal dominant - FHx main risk factor!

Onset is usually at 20-40 years

MAIN SYMPTOMS:

conductive deafness
tinnitus

nb 10% of patients may have a ‘flamingo tinge’ on tympanic membrane, caused by hyperaemia

Question 12

Q

GLUE EAR

what is it?
age of peak onset?
main presenting symptom?

Answer

A

Effectively chronic otitis media with effusion (aka secretory otitis media)

age 2-7 (normally around 2)

symptom:
= conductive HEARING LOSS (often picked up as inattention, language delay at school!)

nb can also present as behavioural problems or balance problems

Question 13

Q

PRESBYCUSIS:

cause?
conductive or sensorineural hearing loss?
bilateral or unilateral?
what do patients often complain of?

Answer

A

AGE-RELATED

BILATERAL

SENSORINEURAL hearing loss

Patients may describe difficulty following conversations

Audiometry shows bilateral HIGH-FREQUENCY hearing loss

Question 14

Q

MENIERE’S DISEASE

age at presentation?
four main symptoms? (which norm most prominent?)
how long do episodes last?
what clinical test is positive?

Answer

A

middle-aged adults

recurrent episodes of:

vertigo (most prominent)
tinnitus
hearing loss (sensorineural)
sensation of fullness or pressure (in one or both ears)

episodes last minutes to hours!

ROMBERG test is positive (close eyes and fall)

nb may also have nystagmus!

Question 15

Q

ACOUSTIC NEUROMA

aka?
which cranial nerves affected? 3 (and what symptoms does this then give?)
diagnostic investigation? 1

Answer

A

aka vestibular schwannoma
(actually more accurate as is a benign tumour of the schwann cells surrounding the vestibular nerve)

cranial nerve EIGHT

hearing loss (sensorineural)
vertigo
tinnitus

cranial nerve FIVE
- absent corneal reflex (IMPORTANT SIGN!)
(can also get trigeminal neuralgia)

cranial nerve SEVEN
- facial palsy (less common)

diagnosis = MRI cerebello-pontine angle
(nb also norm do audiometry too to quantify hearing loss)

ALWAYS refer to ENT surgeons if suspect! (they will manage conservatively or with microsurgery)

nb Bilateral acoustic neuromas are seen in neurofibromatosis type 2

Question 16

Q

Which common drugs are potentially ototoxic? 5

Answer

A

gentamicin (and other amino glycosides - anything ending in MYCIN)
furosemide
aspirin (and some other nsaids)
quinine
some cytotoxics (eg cisplatin and carboplatin)

Question 17

Q

HEARING LOSS

first clinical exam to do?
two clinical tests to do to determine if conductive or sensorineural? (which is which and what does a ‘positive’ test for each mean?)
when are these tests NOT useful?

Answer

A

OTOSCOPY (see if you can visualise any wax or middle ear effusions etc)

RHINNES TEST
= put tuning fork next to ear then on mastoid
- if air conduction (AC) > bone conduction (BC) then it is positive (means either normal hearing or sensorineural hearing loss)
- if BC >AC then is negative (means conductive hearing loss in that ear)

WEBBERS TEST
= put tuning fork on mid forehead
- lateralises to midline: normal hearing OR bilateral disease (conductive or sensorineural)
- lateralises to AFFECTED ear in CONDUCTIVE hearing loss
- lateralises to UNAFFECTED ear in SENORINEURAL hearing loss

NOT useful if bilateral or mixed hearing loss!!

Question 18

Q

HEARING LOSS

after otoscopy + rinnes + webers tests, what is next line investigation? 1
other investigation to consider if unsure of cause? 1
what to do if suddent unilateral hearing loss?

Answer

A

AUDIOMETRY (refer for)
- in all pts to quantify hearing loss

consider imagine (eg CT if unsure of cause - esp if conductive)

refer to ENT urgently if sudden unilateral hearing loss!

Question 19

Q

HEARING LOSS

management option for people with moderate-severe sensorineural hearing loss? 1
if patients are deaf from birth, other management option? 1

Answer

A

Pathology excluded & Patients 50-80 years old? –
refer for HEARING AID (or “assess & fit”) appointments
- nb can also give to younger pts

deaf patients can have COCHLEAR IMPLANTS

nb for conductive hearing loss you treat the cause - eg gromits for glue ear, surgery for any mass

Question 20

Q

VERTIGO:

what is it?
most important causes? 6
other rarer causes? 4

Answer

A

Vertigo may be defined as the false sensation that the body or environment is moving

= viral labyrinthitis
= vestibular neuronitis

= BPPV
= meniere’s

= vertebrobasilar ischaemia
= acoustic neuroma

posterior circulation stroke
trauma
multiple sclerosis
ototoxicity e.g. gentamicin

Question 21

Q

For each of these causes of vertigo:

viral labyrinthitis
vestibular neuronitis
BPPV
meniere’s
vertebrobasilar ischaemia
acoustic neuroma

describe:

1) speed of onset? (and if any preceeding events)
2) what triggers vertigo attacks? (+ how long last)
3) any associated hearing loss or tinnitus? (and any other associated symptoms)

Answer

A

VIRAL LABYRINTHITIS

1) SUDDEN onset (following recent viral infection)
2) no recognised trigger
3) HEARING may be affected, incl tinnitus (also get NAUSEA and vomiting!)

VESTIBULAR NEURONITIS

1) recurrent attacks (following recent viral infection)
2) no recognised trigger
3) NO hearing loss (distinguishes from above! - as only affects vestibular nerve!) (also get nausea and vomiting)

BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV`)

1) Gradual onset
2) triggered by change in head position (each episode lasts 10-20 seconds)
3) NO hearing loss or tinnitus (may get some nausea)

MENIERE’S

1) gradual onset recurrent episodes
2) no trigger although exacerbated by movement, episodes lasts minutes to hours
3) associated with hearing loss, tinnitius and fullness/pressure in ears

VERTEBROBASILAR ISCHAEMIA

1) elderly patients
2) vertigo on EXTENSION of neck
3) no associated symptoms

ACOUSTIC NEUROMA

1) gradual onset
2) no known trigger
3) associated with hearing loss, vertigo, tinnitus (and absent corneal reflex!)

Question 22

Q

LABYRINTHITIS

how to distinguish from vestibular neuronitis? 1
three groups of causes? (which is by far most common?)
average age at presentation?

Answer

A

get hearing loss +/- tinnitus as well as vertigo (in vestibular neuronitis only the vestibular nerve is affected so only get vertigo + nausea)

LABYRINTHISITIS CAUSES

VIRAL (by far most common!)
bacterial (have pus, more unwell)
systemic infection (obs are off)

viral is normally secondary to a recent URTI or herpes!

average age of presentation is 40-60

Question 23

Q

LABYRINTHITIS

Main symptom? (describe onset and severity)
associated symptoms? 3
clinical sign on examination? other sign you may see?
possible prodrome?

Answer

A

VERTIGO

not triggered by movement (but is exacerbated by it!)
SUDDEN onset
is incapacitating
nausea and vomiting (frequent!)

+/- hearing loss
+/- tinnitus

see spontaneous (norm horizontal) nystagmus

other sign = Gait disturbance (fall/lean towards affected side)
(normally fine sitting)

nb may also see abnormality on inspection of the external ear canal and the tympanic membrane e.g. vesicles in herpes simplex infection

POSSIBLE PRODROME

Viral Prodrome (coryza etc)
Rhinorrhoea + Fever

Question 24

Q

HINTS exam

what used to differentiate between?
describe each section and findings?

Answer

A

used to distinguish between a central cause of vertigo (eg stroke) from a peripheral cause (eg labyrinthitis or vestibular neuronitis)

1) Head Impulse test
= (test for peripheral vestibular function)
- Fix pt. gaze straight ahead/at your nose. Rapidly turn pts. head 10-20° to one side and then reset back to face you.
NORMAL = patient holds fixed gaze w/ head movement.
ABNORMAL = saccades present i.e. patients eyes have to flick back to your nose (GET IF PERIPHERAL)

2) Nystagmus Type
- Ask pt. to look left & right to discern whether nystagmus (indicated by the fast phase of movement) is unidirectional & consistent nystagmus = POSITIVE (sign of peripheral cause)
- Nystagmus that changes on position i.e. fast phase to left when looking left and vice versa indicates a central cause (e.g. Stroke/TIA)

3) Skew
- Cover/uncover each eye in turn & note any skew – typically vertical skew. Movement = central causes of vertigo.

SO an abnormal head impulse test, unidirectional nystagmus and no vertical skew are sensitive markers of PERIPHERAL CAUSES of vertigo

Question 25

Q

LABBYRINTHITIS:

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

Answer

A

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)

Question 26

Q

VIRAL LABYRINTHITIS:

when to refer urgently to ENT?
prognosis?
advice to patients? 2
medication to prescribe? 1

Answer

A

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!)

Question 27

Q

Benign paroxysmal positional vertigo (BPPV)

average age of onset?
triggers?
how long episode last for?
what manouvere is positive? 1
what manouvere is performed to treat? 1

Answer

A

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

Question 28

Q

CHOLESTEATOMA

what is it?
risk factors? (age plus another 3)
main two features? 2

Answer

A

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

Question 29

Q

CHOLESTEATOMA

what see on otoscopy? 1
management? 1

Answer

A

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

Question 30

Q

RAMSAY HUNT SYNDROME

what is it? (incl where affected)
first symptom?
subsequent symptoms? 3
medical management? 2

Answer

A

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

Question 31

Q

Difference between primary and secondary otalgia?

causes of primary otalgia? (3 common 2 rarer)

causes of secondary otalgia? (4 common, 3 rarer)

Answer

A

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

Question 32

Q

RED FLAGS in history of OTALGIA

ear symptom? 1
eye symptoms? 2
other symptoms? 5
past medical history? 2

Answer

A

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)

Question 33

Q

describe what each of these words are describing in the eye:

conjunctiva
iris
sclera
pupil
cornea
anterior chamber

Answer

A

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)

Question 34

Q

RED EYE
findings in these conditions:
- acute angle closure glaucoma
- anterior uveitis (iritis)
- scleritis
- conjunctivitis
- subconjunctival haemorrhage

1) brief hx / risk factors?
2) appearance of conjunctiva?
3) appearance of iris?
4) appearance of pupil?
5) appearance of cornea?
6) appearance of anterior chamber?
7) intraocular pressure?

Answer

A

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

Question 35

Q

Initial management of each of these causes of red eye:

acute angle closure glaucoma? 2
anterior uveitis? 2
scleritis? 1
conjunctivitis? 1
subconjunctival haemorrhage? 1

which would you refer to opthalmology?

Answer

A

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)

Question 36

Q

ACUTE ANGLE CLOSURE GLAUCOMA:

- pathophysiology? (ie what causes the raised intra-ocular pressure)

Answer

A

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)

Question 37

Q

ACUTE ANGLE CLOSURE GLAUCOMA:

age generally affected?
long or short-sighted people more at risk?
medications that increase risk?
what is normally the acute trigger?

Answer

A

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)

Question 38

Q

ACUTE ANGLE CLOSURE GLAUCOMA:

classic prodrome symptom? 1
main local symptom? 1
other local symptom? 1
systemic symptoms? 3

Answer

A

HALOES / rainbows around lights!!

constant aching pain develops RAPIDLY around one eye

reduced vision
pain radiates to forehead (headache)
nausea and vomiting
abdo pain

Question 39

Q

ACUTE ANGLE CLOSURE GLAUCOMA, findings on exam / SLIT LAMP:

visual acuity?
conjunctiva/sclera?
iris?
pupil?
cornea?
anterior chamber?
intraocular pressure?

Answer

A

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

Question 40

Q

ACUTE ANGLE CLOSURE GLAUCOMA:

who to refer to? how urgently?
nursing management? 2
two medications to give to treat? 2 (incl route)
two medications to treat symptoms? 2
definitive treatment provided by opthalmologists? 1

Answer

A

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

Question 41

Q

DDx for ACUTE RED EYE (with normal lids)

inflammatory/autoimmune? 3
infectious? 2
secondary to foreign bodies? 2
other? 2

what is the most common cause?

Answer

A

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!

Question 42

Q

CONJUNCTIVITIS

how is the appearance described?
three main types?

Answer

A

‘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

Question 43

Q

CONJUCTIVITIS

symptoms? 4
how to distinguish clinically from viral and bacterial causes? 1
additional feaqtures of allergic conjunctivitis? 2

Answer

A

‘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

Question 44

Q

Management of allergic conjunctivitis:

advice to patient?
medication options? 2

Answer

A

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

Question 45

Q

BACTERIAL CONJUNCTIVITIS:

1st line management option? 1
norm prognosis without this management?
which groups of patients always given to? (3 clinical, 2 occupational)

Answer

A

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

Question 46

Q

BACTERIAL CONJUNCTIVITIS

what to suspect and do if pt fails treatment?
which group of patients should you refer to opthalmologist straight away?

Answer

A

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

Question 47

Q

Three most common causative organisms for BACTERIAL conjunctivitis? 3 (other 2 rarer causes?)

commonest VIRAL cause of conjunctivitis? 1

Answer

A

BACTERIAL
= strep pneumoniae
= staph aureus
= H. influenzae
- gonococcal
- chlamydial

VIRAL
= adenovirus (80%)
^very contagious!!

Question 48

Q

what normally preceedes a viral conjunctivitis?

How long do viral conjucntivits symptom s take to go away? when should you refer someone?

Answer

A

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

Question 49

Q

what can often preceede a bacterial conjunctivitis? 2

Answer

A

Otitis media or LRTI

Question 50

Q

FOREIGN BODY IN EYE:

symptoms common for all? 5 (conjunctiva abrasian, corneal abrasian and penetrating injury)
symptom that makes corneal involvement and/or penetrating injury more likely? 1

nb this is just symptoms, do signs on different flashcard

Answer

A

= 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)

Question 51

Q

EYE INJURY

sign likely to see in all? 1
bedside investigation to look for abrasions? 1
RED FLAG signs for penetrating corneal injury? 5

Answer

A

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)

Question 52

Q

Test to do to see if aqueous humour is leaking from eye:

name?
what it involves?

Answer

A

Seidel’s test

= 10% Fluorescein (dark orange)

check if aqueous fluid is leaking (treat as open globe injury)

Question 53

Q

Who to refer to opthalmology urgently following occular trauma / foreign body?

Answer

A

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

Question 54

Q

Management of:

corneal abrasion? 2
additional management of corneal foreign body (non-penetrating)? 2

ie inaddition to above

Answer

A

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!)

Question 55

Q

Management of penetrating corneal injury:

what NOT to do? 1
who to refer to? 1
how to protect eye in meantime? 1
medication to give in ED? 1

Answer

A

Do NOT touch, manipulate or pad the eye

REFER IMMEDIATELY

Give rigid eye shield to protect eye and refer immediately

Give TETANUS shot

Question 56

Q

CORNEAL ULCER

main risk factor?
causative group of organisms?
do you need to refer to opthalmology?

Answer

A

CONTACT LENSE WEARERS

can be bacterial (commonest), viral (norm HSV) or rarely fungal

YES - REFER URGENTLY!

Question 57

Q

CORNEAL ULCER

often initial symptom?
later symptoms? 4

Answer

A

may start with a ‘foreign body sensation’

then

photophobia
blurred vision
discharge
pain

Question 58

Q

CORNEAL ULCER

signs on exam? 3
additional bedside investigation? 1 (and what does it show?)

Answer

A

severe conjunctival injection
discharge
eyelid swelling

corneal ulceration demonstrated by fluorescein stain

Question 59

Q

CORNEAL ULCER

who manages?
investigation they will do? why?
management options? 2

Answer

A

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!

Question 60

Q

CATARACTS

pathophysiology?
risk factors? (2 demographic, 2 lifestyle, 2 conditions, 1 med)

nb this excludes for con genital

Answer

A

gradual deposiotion of opaque protein deposits onto lense

increased age
female
smoking
UV exposure
diabetes mellitus
inflammatory eye disease
corticosteroids

Question 61

Q

CONGENITAL CATARACTS

infections that can cause? 5
other condition associated with? 1

Answer

A

TORCH

toxoplasmosis
other (VZV, syphillis, HIV)
rubella
CMV
herpes simplex

down’s yndrome

nb can also get idiopathic congenital cataracts

Question 62

Q

ADULT-ONSET CATARACTS

speed of onset?
describe the loss of vision that occurs? (ie what goes first)
associated symptoms? 2

Answer

A

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)

Question 63

Q

CONGENITAL CATARACTS

test to pick up?
signs if missed? 3
how quickly do you need to operate to reduce adverse effects? 1

Answer

A

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!

Question 64

Q

CATARACTS

findings on fundoscopy? 2
investigation for definitive diagnosis?

Answer

A

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 65

A

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 66

A

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 67

A

= chronic blepharitis

rosacea
seborrhoeic dermatitis
pregnancy
diabetes mellitus

nb most people who get one don’t have any reisk factors

Answer 68

A

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 69

A

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 70

A

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 71

A

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 72

A

cataracts
glaucoma

(nb also high risk for hypertensive retinopathy too!)

Answer 73

A

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 74

A

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 75

A

Treat primarily by CONTROLLING BP (meds and lifestyle)

for retinal edema, sometimes:

laser
intravitreal steroid injection - injeciton of antivascular endothelial growth factor drugs

Answer 76

A

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 77

A

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 78

A

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 79

A

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 80

A

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 81

A

lubricating eyedrops
skin tape (esp at night)
surgery

Answer 82

A

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 83

A

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 84

A

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 85

A

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 86

A

Episcleritis
- self-limiting so reassure
- give topical NSAIDs (diclofenac /ketorolac)
(+/- artificial tears)

Scleritis
- urgent opthalm referral (risk of sclera thinning and globe perforation)

Answer 87

A

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 88

A

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 89

A

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 90

A

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 91

A

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 92

A

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 93

A

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 94

A

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 95

A

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 96

A

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 97

A

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 98

A

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

Answer 99

A

Perforations irritate!

WHISTLE noise
Crust
Epistaxis

Answer 100

A

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

Answer 101

A

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 102

A

CT head!

Conservative Mx – bed rest, self resolves 7-10 d

Cover with:

Abx
Pneumococcal vaccine

Answer 103

A

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 104

A

sneezing
bilateral nasal obstruction
clear nasal discharge
post-nasal drip
nasal pruritus

atopic conditions (eczema, asthma, allergies)

Answer 105

A

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 106

A

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 107

A

FACIAL pain
- typically frontal pressure pain which is WORSE on BENDING FORWARD

nasal discharge (norm thick and purulent)
nasal obstruction (feeling)

Answer 108

A

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 109

A

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 110

A

avoid allergen

intranasal corticosteroids
nasal irrigation with saline solution

nb irrigation not proven benefit for acute sinusitis but usefuyl for chronic

Answer 111

A

unilateral symptoms
persistent symptoms despite compliance with 3 months of treatment
epistaxis

if get any of these - consider ENT referral

Answer 112

A

male
adults
asthma
aspirin sensitivity
infective sinusitis

nb Nasal polyps are NOT associated with allergy

CF
kartagener syndrome
churg-strauss syndrome

Answer 113

A

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

Answer 114

A

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 115

A

children with nasal polyps

always screen for cystic fibrosis!!

Answer 116

A

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 117

A

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 118

A

teenagers
M>F

cushings
- disease or anabolic steroid use!

Answer 119

A

MILD
- facial comedones

MODERATE
+ inflammatory lesions, face +/- torso

SEVERE
+ nodules
+ cysts
+ scars

Answer 120

A

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 121

A

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 122

A

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 123

A

Multiple sexual partners
DM
immunocomp
pregn
COCP

Answer 124

A

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 125

A

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 126

A

other STIs!!

chlamydia
gonorrhoea
syphillis
HIV

Answer 127

A

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 128

A

wear condoms!! (reduces risk, risk not zero!)

stop smoking (smoking increases risk of recurrence!)

Answer 129

A

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 130

A

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 131

A

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 132

A

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 133

A

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 134

A

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 135

A

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 136

A

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 137

A

sun exposure
white!
HPV
chemical exposure (arsenic, soot, tar)
radiotherapy

nb having a pre-malignant condition (bowens / actinic keratosis) also increases your risk!

Answer 138

A

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 139

A

5%

increased risk:

near orifices (esp lip/ear)
> 2cm diameter
depth >4mm
poor differentiation
recurrence

Answer 140

A

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 141

A

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 142

A

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 143

A

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 144

A

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 145

A

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 146

A

BRAFV600
in 50% of melanomas!

do genetic testing to see if have

Answer 147

A

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 148

A

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 149

A

venous
arterial
neuropathic/diabetic

Answer 150

A

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 151

A

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 152

A

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 153

A

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 154

A

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 155

A

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 156

A

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 157

A

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 158

A

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 159

A

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 160

A

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 161

A

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 162

A

cervical chain lymph nodes!

learn where these are again!!!

Answer 163

A

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 164

A

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 165

A

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 166

A

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 167

A

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 168

A

strabismus

eso = looking medial (aka convergent)

exo = looking lateral (aka divergent)

hypo = looking down

hyper = looking up

Answer 169

A

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 170

A

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 171

A

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 172

A

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 173

A

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 174

A

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 175

A

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 176

A

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 177

A

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 178

A

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 179

A

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 180

A

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 181

A

presents 1-2 weeks following onset of
pharyngitis

‘cola-coloured urine’ (blood + protein - nephritic syndrome!)
periorbital edema
malaise
decreased appetite

Answer 182

A

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 183

A

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 184

A

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 185

A

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 186

A

foreign body aspiration
tonsilar abscess (quinsy)
croup
anaphylaxis
laryngomalacia

Answer 187

A

resp arrest -> death
abscess
sepsis
meningitis
pneumothorax

Answer 188

A

neck lump
hoarseness
persistent sore throat
persistent mouth ulcer

nb dysphagia is more commonly oesophageal Ca

Answer 189

A

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 190

A

people aged 45 and over

AND

persistent unexplained hoarseness
OR
an unexplained lump in the neck

Answer 191

A

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 192

A

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 193

A

voice overuse
smoking
laryngeal cancer
lung cancer
viral illness
hypothyroidism
gastro-oesophageal reflux

consider doing CXR (to exclude apical lung lesions!)

Answer 194

A

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