ENT & Eyes Flashcards
most common eyelid tumour.
Basal cell carcinoma
They are characteristically described as having a pearly sheen with rolled edges and an ulcerated centre.
They do not metastasise but cause problems via local invasion.
Risk factors
Risk factors include: sun exposure, immunosuppression, and some rare inherited syndromes (e.g. xeroderma pigmentosa and Gorlin Goltz syndrome.)
Blepharitis
sore, itchy eyelid margins with a crusty appearance at the base of the eyelashes. The condition cannot be cured, but it very rarely causes damage to eyesight.
Treatment is aimed at controlling the symptoms with good eyelid hygiene. Warm compresses should be applied twice daily to clean debris from the eyelid margins.
carotid cavernous fistula
abnormal communication between the carotid artery and the cavernous sinus.
Causes
It may be spontaneous or secondary to trauma and presents with pulsatile proptosis, a bruit and severely injected conjunctiva. The cranial nerves that run through the cavernous sinus may be affected.
Complications
of cataract surgery
Endophthalmitis is the most dangerous complication and the first thing any doctor should rule out when presented with a patient complaining of visual symptoms following intraocular surgery. Patients typically present within days of surgery with severe pain, loss of vision and hyperaemia. They should be admitted and seen immediately by an ophthalmologist.
Posterior lens capsule opacification is a relatively common complication of cataract surgery that usually occurs a few weeks following the operation. The typical patient complains of blurry vision as if their cataract has returned, and a white opacity may be visible on observation. The condition can be treated easily with a simple laser procedure which can be carried out as an outpatient.
Risk factors for cataracts include:
Age Smoking Diabetes Alcohol Sunlight exposure Corticosteroid use Trauma Previous eye surgery
Central retinal vein occlusion
sudden painless loss of vision
widespread hyperaemia and haemorrhages, often likened to a ‘stormy sunset’
Central retinal vein occlusion RF
Risk Factors
Old age, hypertension, diabetes mellitus, polycythaemia, and arteriosclerosis are important risk factors
Chronic open angle glaucoma
loss of peripheral fields as well as a central scotoma in advanced disease. Fundoscopy may reveal optic disc cupping, where the cup appears large in relation to the optic disc.
topical beta blocker or prostaglandin analogue.
Beta blockers (e.g. Timolol) – Reduce aqueous production
Prostaglandin analogues (e.g. Latanoprost) – Increase uveoscleral outflow
Carbonic anhydrase inhibitors (e.g. Dorzolamide) – Reduce aqueous production
Sympathomimetics (e.g Brimonidine) – Reduce aqueous production & increase uveoscleral outflow
Miotics (e.g. Pilocarpine) – Increase uveoscleral outflow
red eye,
Acute angle-closure glaucoma
Anterior uveitis
Scleritis
Acute angle-closure glaucoma features
systemically unwell with nausea and headaches.
Pain with lurred vision and haloes around lights.
fixed dilated pupil
Anterior uveitis features
red eye, pain, blurred vision and photophobia.
increased lacrimation from the affected eye.
Differentials of diplopia
Third nerve palsy Fourth nerve palsy Sixth nerve palsy Myasthenia gravis Strabismus MS
Fourth nerve palsy
ye points upwards and inwards and the patient may present with a tilted head to compensate for the palsy.
Sixth nerve palsy
medially deviated at rest, and diplopia worsens when the patient is asked to look horizontally away from the midline.
Endophthalmitis
infection inside the globe and most commonly occurs after surgery
intravitreal vancomycin
Horner’s syndrome
ptosis, meiosis with or without anhydrosis.
Pancoast tumour (affecting sympathetic nerve supply)
Stroke
Carotid artery dissection (Red flag: neck pain)
hypertensive retinopathy
Grade I – Vascular attenuation (or narrowing of the retinal arteries)
Grade II – Above + AV nipping
Grade III – Above + retinal haemorrhages, hard exudates and cotton wool spots
Grade IV – Above + optic nerve oedema
Ocular side effects of steroid
Steroids have several ocular side effects. These include:
Raised intraocular pressure
Glaucoma
Accelerated cataract formation
Worsening of some types of viral and bacterial corneal ulcers through its immunosuppressive effects
Onchocerciasis
Itchy eyes Ocular Pain Photophobia Blurred vission Glaucoma Night blindness Progression to blindness
Oral ivermectin
Some of the important causes of optic disc pallor are listed below:
Glaucoma due to raised intraocular pressure
Retinitis pigmentosa
Choroiditis
Central retinal artery occlusion
Multiple sclerosis
Leber’s optic atrophy (or Leber’s hereditary optic neuropathy)
Syphilis
Preseptal cellulitis refers to infection of tissue not spreading past the orbital septum.
swollen eyelid, mild fever and erythema surrounding the orbit.intravenous empirical antibiotics. If there is doubt over the diagnosis, treat it as orbital cellulitis.
Orbital cellulitis
Painful eye movements
Diplopia
Visual impairment
feverish child with a swollen eyelid, reduced eye mobility, painful eye movements, and diplopia in some - reduced visual acuity, ‘red desaturation’ and a relative afferent pupillary defect.
Patients should be admitted for immediate CT scan, ENT review and urgent intravenous antibiotics.
Posterior vitreous detachment
photopsia and floaters
central retinal artery occlusion (CRAO)
onset painless loss of vision that typically occurs over seconds.
The classic view on fundoscopy is that of a pale retina with a cherry red spot at the macula
Retinitis pigmentosa
Retinitis pigmentosa
atients often present at a young age with ‘tunnel vision’ due to damage to the peripheral retina from pigment deposits. As rod cells are primarily affected in most types, patients also classically complain of reduced visual acuity in dim light.
Fundoscopy findings
Characteristic fundoscopy findings include peripheral bone-spicule pigmentation, optic disc pallor and retinal vessel attenuation.
Centor Criteria tonsillitis
History of fever.
Tonsillar exudates.
No cough.
Tender anterior cervical lymphadenopathy.
Complications of tonsillitis
Recurrent Tonsillitis
Retropharyngeal Abscess
Peritonsillar Abscess (Quinsy) (sore throat, dysphagia, peritonsillar bulge, uvular deviation, trismus and muffled voice)
Lemierre’s syndrome (Inflammation leads to pharyngotonsilitis and leads inflammation within the internal jugular vein and septic emboli.)
Acute rhinosinusitis
nasal blockage/congestion OR nasal discharge as well as 1 of facial pain/pressure OR loss/reduction of sense of smell.
Management
In symptoms lasting <5 days or improving thereafter, appropriate treatment is with paracetamol, nasal saline irrigation and decongestants.
For symptoms lasting >10 days, or worsening after 5 days, topical steroids and antibiotics should be considered.
Benign paroxysmal positional vertigo (BPPV)
provoked by movements of the head usually to one side when turning in bed or on looking upwards.
These sudden attacks of rotational vertigo last for 30s to 1 minute and are provoked the changing position of the head.
There are no auditory symptoms for BPPV.
Episodes will usually abate and disappear within a few weeks or months, but they often recur.
Diagnoisis = dik-hallpike
Treatment = Epley manoeuvre.
CSF rhinorrhoea
Causes of CSF rhinorrhoea include:
Fracture of the anterior skull base
Iatrogenic following surgery
Spontaneous leak
current standard in diagnosis of anterior skull base fracture is CT (axial and coronal planes).
Cholesteatoma
complication of chronic otitis media and commonly occurs in younger patients (aged 5-15 years old).
= abnormal accumulation of skin, squamous epithelium within the middle eat cleft and mastoid air cells.
symtoms - persistent foul smelling discharge, headache and otalgia.
first-line management for epistaxis
Direct compression of the nasal alae
f direct compression of the nasal alae for 10-15 minutes does not resolve epistaxis -> e nasal cautery as there is a visible bleeding site
nasal cautery for epistaxis
topical anaesthetic spray and vasoconstrictor applied
Cautery can either be chemical or electrical (thermal).
Head and Neck Neoplasia
Risk factors
Smoking
Alcohol misuse
Viral infections including human papilloma virus (HPV) infection (type 16 in particular) and Epstein Barr Virus (EBV) infection
Radiation exposure (UV and ionizing radiation e.g. CT scans)
Immunosuppression (organ transplantation)
Occupational exposure (acid mists, asbestos, wood dust)
Family history
Hereditary haemorrhagic telangiectasia
rare genetic disorder characterised by abnormal blood vessel formation
Clinical presentation Epistaxis Anaemia symptoms Gastrointestinal blood loss Embolic manifestations e.g. stroke and myocardial infarction
Hoarseness lasting more than 3 weeks
referred under a 2 week wait to ENT clinic.
Chronic Laryngitis
Hoarseness associated with gastroesophageal reflux disease.
It commonly presents as worse in the morning.
Reinke’s Oedema
Caused by enlargement of the vocal cords and is associated with hypothyroidism it leads to prolonged and persistent hoarseness.
Meniere’s disease
Meniere’s disease is caused by the dilatation of the endolymphatic spaces of the membranous labyrinth causing episodes of vertigo lasting for 12-24 hours.
Attacks of sudden paroxysmal vertigo with associated deafness and tinnitus.
Attacks normally occur in clusters with periods of remission where function is recovered.
Management relies on prophylactic use of betahistine to reduce the frequency of attacks, and the acute use of prochlorperazine.
Surgical approaches lack a strong evidence base.
Septal haematoma
ENT for emergency incision and drainage.
Emergency incision & drainage prevents both life-threatening infective complications and severe cosmetic nasal deformity.
Otitis externa managment
mild - topical drops including combined antibiotic/steroid drops
servere: Where the meatus is completely occluded and there is significant swelling of the external meatus may be treated using a strip of ribbon gauze known as “Pope” wicks which can be used for the application of topical antibiotics (classically gentamicin) enabling deeper penetration.
Indications to Consider Oral Antibiotics
Otitis externa
Cellulitis extending beyond the external ear canal
When the ear canal is occluded by swelling and debris, and a wick cannot be inserted
People with diabetes or compromised immunity, and severe infection or high risk of severe infection, for example with Pseudomonas aeruginosa
Otitis Media
Management
admit any children under 3 months with a temperature of 38 or more, or children with suspected acute complications of otitis media such as meningitis, mastoiditis or facial nerve palsy
Most children will not require antibiotics. A delayed antibiotic prescribing strategy can also be appropriate. This involves asking patients/parennts to start taking antibiotics if symptoms don’t improve within four days.
Extra-cranial Complications of Otitis Media
Facial nerve palsy:
Mastoiditis
Petrositis (otorrhoea, pain deep inside the ear and the eye and ipsilateral VI nerve palsy.)
Quinsy
managment
Antibiotics and aspiration are now preferred to the traditional incision and drainage.
Risk Factors for Nasopharyngeal Carcinoma
Chinese ethnicity Male Diets with high salt intake Cured meats Fish (common in parts of Asia) EBV infection Family history Tobacco smoking Alcohol
Salivary tumours
Benign Tumour types
Pleomorphic adenoma (aka mixed tumor) ~80%
Mucoepidermoid Carcinoma ~8%
Warthin’s tumor ~7%
Salivary tumours
Malignant Tumours types
Malignant tumours will commonly present with invasion of other structures leading to focal neurology, particularly invasion of the facial nerve leading to a VII nerve palsy.
Malignant tumours include:
Adenoid cystic carcinoma
Mucoepidermoid carcinoma
Acinic cell carcinoma
Thyroglossal Cyst
fluctuant, painless midline neck mass in children. The cyst may become infected, and is usually treated with surgical excision
Pathological conditions associated with tinnitus include:
Chronic noise exposure Presbycusis Acute acoustic trauma Perforation of the tympanic membrane Otitis media Meniere's disease Vestibular schwannoma Ototoxic drugs (quinine, aminoglycosides, loop diuretics) Trauma
Tympanosclerosis
hronic inflammation and scarring of the tympanic membrane leading to subsequent calcification of the tympanic membrane and associated structures.
associated with long term otitis media and tympanostomy (grommet) insertion.
Management
Hearing aids are a common treatment for hearing loss disorders.
In cases refractory to hearing aids, excision of the sclerotic areas and repair of the ossicular chain may be considered.
Dacryocystitis
infection of the lacrimal sac of the eye, which usually occurs due to blockage of the nasolacrimal (tear) duct. It typically presents with pain and tenderness over the medial canthus and watering of the eye.
. Treatment is with systemic oral antibiotics and analgesia. The infection can spread, causing conjunctivitis or orbital cellulitis.
Steroids have several ocular side effects. These include:
Raised intraocular pressure
Glaucoma
Accelerated cataract formation
Worsening of some types of viral and bacterial corneal ulcers through its immunosuppressive effects
Pterygium
vergrowth of the conjunctiva onto the surface of the cornea.
educed visual acuity and irritation of eye. Pterygium is visible as a white fibrous opacity present over the corneum, continuous with the conjunctiva.
Types of Uveitis
Anterior uveitis – Inflammation of the anterior uvea, comprising of the iris and ciliary body.
Intermediate uveitis – Inflammation of the vitreous.
Posterior uveitis – Inflammation of the choroid.
Panuveitis – Inflammation of all of the above.
Intermediate uveitis
Patients typically present with floaters and painless blurred vision. On slit lamp examination, cells may be visualised in the vitreous and on fundoscopy ‘snowballs’ and ‘snow banking’ may be visualised.
Vitamin A Deficiency
Presentation
Presentation
Ocular (normally bilateral)
Night blindness Conjunctivaland corneal dryness Keratomalacia Bitot's spots - irregular foamy patches on the whites of the eye. Corneal perforation Other
Dry skin and hair
Brittle nails
Follicular hyperkeratosis
Increased infections
