ENT and Ophthalmology Flashcards
What are common bacterial causes of tonsillitis?
Group A streptococcus (pyogenes most common)
Strep. pneumoniae
HiB
Morazella catarrhalis
Staphylococcus aureus
Consider the clinical presentation of a child with tonsillitis - what would their signs and symptoms be?
- Fever, sore throat, painful swallow
- Swollen lymph nodes (cervical)
- Red, inflamed tonsils with or without exudate
- Younger patients - Sx are less specific
What are the four criteria of the Centor Criteria?
- Fever >38oC
- Tonsillar exudate
- Absence of cough
- Lymphadenopathy of anterior cervical lymph nodes (tender)
How many of the Centor Criteria are required to be met for antibiotics to be advised (tonsillitis)?
3
What are the criteria for the FeverPAIN score?
- Fever during previous 24 hours
- P - Purulence; pus on tonsils
- A - Attended within 3 days of symptoms onset
- I - Inflamed tonsils
- N - No cough or coryza
Taking into account the patient’s FeverPAIN score following a tonsillitis diagnosis, what should a physicians action be?
2-3 - middling probability of bacterial tonsillitis; consider watchful waiting
4-5 - higher (65%) chance of bacterial tonsillitis
Centor and FeverPAIN scores above what then consider antibiotics?
3 and 4 respectively
What is the antibiotic of choice for bacterial tonsillitis and for how long?
Phenoxymethylpenicillin (10 days)
What is an alternative antibiotic for tonsillitis should the patient have a penicillin allergy?
Clarithromycin
What are the complications of tonsillitis in paediatrics?
Chronic
Otis media (spreads to inner ear)
Quinsy
What is quinsy?
Peritonsillar abscess arising should a bacterial infection form an abscess in the tonsillar region
What are the common bacterial causes of quinsy?
GAS (pyogenes)
Staphylococcus aureus, Hib
What are the signs of quinsy that would make one think that it might not just be limited tonsillitis?
Sore throat, painful swallow, fever
Swollen, tender lymph nodes
Trismus (can’t open mouth), hot potato voice, swelling and erythema behind tonsils
Antibiotic of choice for quinsy?
Co-amoxiclav (broad spectrum)
Alongside antibiotics what may be prescribed for a patient with quinsy?
Steroids (dexamethasone), incision and drain, abx
What are the number of episodes of tonsillitis per year required for a tonsillectomy (think one year, two year, three year)?
One year: 7/yr
2 year: 5/yr
3 year: 3/yr
Other than frequency what are two indications for tonsillectomy?
Recurrent tonsillar abscess (2 episodes)
Enlarged tonsils leading to issues breathing, sleeping, swallowing
What is otitis media?
Infection of the middle ear (space between tympanic membrane and inner ear) where the cochlea, vestibular apparatus and nerves are found
How does otitis media come about?
Bacteria enter from the back of the throat through the eustachian tube (often preceded by a viral URTI)
What are the bacterial causes of otitis media (+most common)?
Most common: strep pneumoniae
Haemophilius influenzae
Moraxella catarrhalis
Staphyloccocus aureus
A child presents with ear pain with reduced hearing. They have a fever, cough and sough throat and have been feeling unwell since last night. Their mother reports that there was some discharge coming from their ear. What is a possible diagnosis?
Otitis media
Discharge is due to the perforation of the tympanic membrane
What is a normal examination in a patient (suspect otitis media)?
Pearly-grey, translucent, shiny, reflecting cone of light
What is a pathological examination in a patient (suspect otitis media)?
Bulging, red, inflamed looking membrane, discharge in the ear canal and hole in the tympanic membrane.
What is the treatment for otitis media (1st line abx and length)?
1st line - Amoxicillin for 5 days (alternatively erythromycin and clarithromycin)
What is glue ear?
Middle ear is full of fluid so there is hearing loss in that ear (could be due to blockage of the Eustachian tube)
What is the investigation of choice for glue ear?
Otoscopy: shows dull tympanic membrane w/ air bubbles or visible fluid level
What is the management for glue ear?
- Conservative support (resolve within 3 months)
- Hearing aids
- Refer for audiometry
What are grommets?
Small tubes inserted into the tympanic membrane by ENT surgeon allowing fluid drainage
What is the passage of grommet fluid drainage?
Out of the middle ear through the tympanic membrane to the ear canal
What are congenital causes of hearing loss?
Maternal rubella or CMV during pregnancy
Genetic conditions
What is Wardenbergs Syndrome?
Congenital sensorineural hearing loss
What is the genetic pattern of Treacher Collins hearing loss?
Autosomal dominant conductive hearing loss
What are the characteristics of Treacher Collins?
Abnormal outer and middle ear with cheek bone underdevelopment (and hearing loss)
What are two perinatal causes of hearing loss?
Prematurity
Hypoxia during/after birth
What are causes of hearing loss after birth (x4)/?
- Jaundice
- Meningitis and Encephalitis
- Otitis media or glue ear
- Chemotherapy
What may a concerned parent report about a child with hearing problems?
Ignore calls/sounds
Poor speech/language development
Poor school performance
Frustration or bad behaviour
What is an audiogram?
Chart documenting the volume patients can hear different tones
What are the readings for normal hearing?
All readings between 0 and 20dB on top of chart
What will be the audiogram readings for conductive hearing loss (problem with the middle ear)?
- Bone conduction: 0-20dB
- Air conduction: >20dB (plot below 20dB line)
What is the pathophysiology of the conductive hearing loss?
Sound is not conducted through the air due to pathology along route into the ear.
What will be the audiogram readings for sensorineural hearing loss?
Both air and bone conduction readings >20dB (plot below the 20 dB line)
What is the pattern of sensorineural hearing loss?
Will affect both the ears equally
What will be the audiogram readings for mixed hearing loss be?
Bone and air conduction readings of >20dB (plot below the 20dB line)
Which will be higher and to what degree on audiogram for mixed hearing loss?
Bone conduction will be >15dB higher than air conduction
Which area of the ear is affected in sensorineural hearing loss?
Inner ear
Management for conductive hearing loss?
Hearing aid offered for persistent loss
Can spontaneously resolve over time/operable.
Management for sensorineural hearing loss?
Usually permanent
–> aim is to raise the level of hearing with cochlear implants recommended
What is the management of mixed hearing loss?
Hearing aid issued to help make all parts of speech audible (especially high Hz).
What is strabismus?
Misalignment of the eyes causing double vision.
What is the risk of an untreated squint (strabismus) in 2-3% of children?
Amblyopia - permanent loss of visual acuity in one eye
What are the causes of amblyopia?
Refractive error, squints, visual deprivation (cataracts, ptosis)
What will happen if treatment is delayed beyond 7 years (for strabismus)?
Large risk the vision on the lazy eye will not improve
What is esotropia?
Inwards pointing squint towards the nose
What is exotropia?
Outward pointing squint towards the ear
What is hypertropia?
Upward moving affected eye
What is hypotropia?
Downward moving affected eye
Name some causes of strabismus? (+most common)
- Idiopathic (large majority)
- Hydrocephalus
- Cerebral palsy
- Space occupying lesion (e.g. retinoblastoma)
What are simple tests to test the presence of strabismus?
Hirschberg’s test
Cover tests
Corneal light reflex (non-specific)
What are potential managements for strabismus?
Treat early
Occlusive patch of good eye
Corrective lenses if refractive error
What can be used to cause vision blurring in strabismus treatment?
Atropine drops
What is blepharitis?
Inflammation of the eyelid margins
What are the clinical features of blepharitis?
Gritty, itchy, dry sensation in the eyes
What cause blepharitis?
Meibomian gland dysfunction
–> Gland that secreted oil onto the eye surface
What is the management of blepharitis?
Lubricating eye drops:
- Hypromellose
- Polyvinyl alcohol
- Carbomer
What is a stye?
Tender red lump around the eyelid that may contain pus
What is hordeolum externum?
Infection of the gland of Zeis (sweat glands at base of eyelashes) or glands of Moll (sebaceous glands at base of eyelash)
What is hordeolum internum?
Infection of meibomian glands - deeper and more painful
What is the management for styes?
Hot compresses and analgesia
Topical antibiotics (choramphenicol) if associated with conjunctivities
What is a Chalazion?
Meibomian cyst - gland blocked and swells
What are the clinical features of chalazion?
Swelling in the eyelid; tend to not be tender
What antibiotic should be considered for chalazion?
Chloramphenicol
Also should be hot compress and analgesia
What is entropion?
Eyelid turns inwards with lashes against eye
What are the clinical features of entropion?
Pain and potential corneal damage/ulceration
What is the management of entropion?
Same day referral to ophthalmology. Tape down eyelid; lubricating eye drops
Surgical intervention
What is ectropion?
Eyelid turning outwards with the inner aspect of the eyelid exposed (usually bottom)
What are the clinical features of ectropion?
Exposure keratopathy (eyeball exposed and inadequately lubricated and protected)
What is the management for ectropion?
Lubricating eyedrops to protect eye surface (surgery to correct defect)
What is trichiasis?
Inward growth of eyelashes resulting in pain and corneal damage and ulceration
What is the management of trichiasis?
Epilation, electrolysis and cryotherapy
What is orbital cellulitis?
Infection around the eyeball that involves tissues behind the orbital septum
What are the clinical features of orbital cellulitis?
Think to differentiate it from periorbital cellulitis
Pain on eye movement
Reduced eye movement
Visual changes
Abnormal pupillary reaction
Proptosis
What is the treatment for orbital cellulitis?
Medical emergency - prompt admission and treat with broad spectrum antibiotics with surgical drainage
