ENT and ophthalmology

Question 1

What is otitis media

Answer 1

infection of the middle ear

Question 2

What usually precedes otitis media

Answer 2

viral upper respiratory tract infections

Question 3

Give 3 bacteria that commonly cause otitis media

Answer 3

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis

Question 4

Describe the presentation of otitis media

Answer 4

• ear pain (otalgia)
• hearing loss
• fever
• ear discharge if tympanic membrane perforates

Question 5

Give 4 possible otoscopy findings of otitis media

Answer 5

• bulging tympanic membrane → loss of light reflex
• opacification or erythema of the tympanic membrane
• perforation with purulent otorrhoea (ear drainage)
• decreased mobility if using a pneumatic otoscope

Question 6

How is otitis media diagnosed

Answer 6

Criteria
* acute onset of symptoms
* presence of a middle ear effusion
* inflammation of the tympanic membrane

Question 7

How is otitis media managed

Answer 7

• majority are self-limiting and only need analgesia
• parents should be advised to reattend if symptoms haven’t improved after 3 days
• amoxicillin for 5 days, alt - erythromycin or clarithromycin

Question 8

Under what circumstances should antibiotics be prescribed at initial presentation of otitis media

Answer 8

• Symptoms lasting more than 4 days or not improving
• Systemically unwell
• Immunocompromise or high risk of complications
• Younger than 2 years with bilateral otitis media
• Otitis media with perforation and/or discharge in the canal

Question 9

Complications of otitis media

Answer 9

• mastoiditis
• meningitis
• brain abscess
• facial nerve paralysis

Question 10

What is glue ear

Answer 10

otitis media with an effusion

Question 11

RFs for glue ear

Answer 11

• male sex
• siblings with glue ear
• higher incidence in Winter and Spring
• bottle feeding
• day care attendance
• parental smoking

Question 12

Features of glue ear

Answer 12

• hearing loss is usually the presenting feature
• secondary problems - speech and language delay, behavioural or balance problems
• peaks at 2 years of age

Question 13

How is glue ear managed

Answer 13

• active observation for 3 months - no intervention is required
• grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube
• adenoidectomy

Question 14

What is a squint

Answer 14

misalignment of the eyes
aka strabismus

Question 15

What is the complication of untreated childhood squints

Answer 15

amblyopia (lazy eye) - the brain fails to fully process inputs from one eye and over time favours the other eye

Question 16

What are concomitant squints

Answer 16

Due to imbalance in extraocular muscles
Convergent (inwards) is more common than divergent (outwards)

Question 17

What causes paralytic squints

Answer 17

paralysis of extraocular muscles

Question 18

How is a squint investigated

Answer 18

• Cover test: ask the child to focus on an object, cover one eye, observe movement of uncovered eye, cover other eye and repeat test
• corneal light reflection test: holding a light source 30cm from the child’s face to see if the light reflects symmetrically and centrally on their cornea

Question 19

How is a squint managed

Answer 19

• refer to secondary care (ophthalmology)
• occlusive eye patch to cover good eye

Question 20

What is periorbital cellulitis

Answer 20

infection of the soft tissues anterior to the orbital septum - this includes the eyelids, skin and subcutaneous tissue of the face, but not the contents of the orbit

Question 21

Give 3 causative organisms of periorbital cellulitis

Answer 21

• staph. aureus
• Staph. epidermidis
• streptococci

Question 22

How does periorbital cellulitis present

Answer 22

• red, swollen, painful eye - acute onset
• erythema and oedema of eyelid
• Partial or complete ptosis of the eye due to swelling

Question 23

How is periorbital cellulitis investigated

Answer 23

• raised CPR/ ESR
• Swabs of any discharge
• contrast CT of orbit may help to differentiate between periorbital and orbital cellulitis

Question 24

How is periorbital cellulitis managed

Answer 24

• referral to secondary care
• oral antibiotics - co-amoxiclav TDS for 7 days

Question 25

Give 4 RFs for orbital cellulitis

Answer 25

• Childhood
• previous sinus infection
• Lack of Haemophilus influenzae type b (Hib) vaccination
• Recent eyelid infection/ insect bite on eyelid (periorbital cellulitis)
• ear/ facial infection

Question 26

Most common bacterial causes of orbital cellulitis

Answer 26

• Streptococcus
• Staphylococcus aureus
• Haemophilus influenzae B

Question 27

How does orbital cellulitis present

Answer 27

• Redness and swelling around the eye
• Severe ocular pain
• reduced visual acuity
• Proptosis (bulging)
• pain with eye movements
• Eyelid oedema and ptosis
• Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)

Question 28

How is orbital cellulitis investigated

Answer 28

• FBC - raised WBC, CPR/ ESR
• Clinical exam - Decreased vision, afferent pupillary defect, proptosis
• CT with contrast - assess posterior spread of infection
• blood culture and swabs to determine causative organism

Question 29

How is orbital cellulitis managed

Answer 29

• medical emergency - admission to hospital
• IV antibiotics (cefotaxime or clindamycin) due to risk of cavernous sinus thrombosis and intracranial spread
  *

Question 30

What presentation would differentiate orbital from preseptal cellulitis

Answer 30

reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis