ENT Opho Flashcards
1
Q
What are the types of chronic rhinitis?
A
non allerhic perennial rhinitis
allergic seasonal rhinitis/hayfever
allergic perennial rhinitis (house dust)
2
Q
How will the 3 different conditions above differ in history?
A
present all year with no relation to allergy- non allergic perennial rhinitis (no itching of ears nose throat
allergic seasonal rhinitis/hayfever caused by pollen in pollen season
allergic perennial rhinitis present all year caused by house dust
3
Q
What are predisposing factors for chronic rhinosinusitis?
A
Allergy Bacterial infection CF PCD Immunocompromised Atmospheric irritants- smoke and dust Hormonal Trauma Swimming and diving
4
Q
What is a nasal polyp?
A
Abnormal mucosal mass presenting due to inflammation of nasal mucosa
5
Q
How do you investigate chronic rhinosinusitis?
A
Allergy test
CT sinuses
Nose and sinus endoscopy
Swabs for causative organisms
6
Q
How can you manage chronic rhinosinusitis if no polyps?
A
No cure;
Conservative -Avoid allergens, Nasal douche
Medically - Topical steroids- spray or drops
Anti-histamines in allergic patients
3 month course macrolides
immunotherapy last resort in allergic to pollen
Surgically
7
Q
What anti-histamines may be used and how do they work?
A
cetirizine, fexofenadine
dry excess mucus
8
Q
What steroid drops can be used and how do they work?
A
Nasonex (Mometasone furoate), reduce swelling
9
Q
What surgical methods can be used?
A
Nasal polypectomy if polyps
Functional sinus surgery to improve drainage of sinuses
10
Q
How can you manage chronic rhinosiniusitis if polyps?
A
Oral steroids 5 days upto 50mg (no more than twice a year)
Anti-leukotrienes
11
Q
Give causes for nasal polyps?
A
Vasculitis Asthma CF Aspirin sensitivity Sinusitis
12
Q
What are the signs and symptoms of nasal polyps?
A
Rhinoohoea
Headaches
Reduced smell and taste
Postnasal drip
13
Q
How can nasal polyps be examined?
A
Nasal speculum
14
Q
How are they managed?
A
Steroids can shrink
Surgical removal if no improvement
Refer if worried about cancer/bleeds/blocked nostril
15
Q
Where does nose bleed usually come from?
A
littles area
Anterior and Posterior Ethmoidal arteries
Sphenopalatine artery
Greater palatine artine artery
Superior labial artery
16
Q
Give causes for nose bleeds?
A
idiopathic Trauma/ iatrogenic Polyps Neoplastic HTN Coagulopathies Vasculitis
17
Q
Describe the management of a nose bleed acutely?
A
ABC
Pinch below bridge of nose
Lead forward
Lidocaine and phenylephrine combination
Phenylephrine soaked material in nose to vasoconstrict
Lidocaine is used to pain relief so nose can be examined
cautery with silver nitrate or bipolar diathermy
Anterior nasal packing- lubricate tampon then insert
Posterior nasal packing
18
Q
When does a nose bleed need to go to A and E?
A
15 mins
>30 mins and on blood thinning meds
19
Q
What is it important to find out? nose bleed
A
Find out if anterior or posterior bleed
If allergic to peanuts- cannot give neseptin cream in management if allergic to peanutes
20
Q
Which vessel is ligated?
A
Sphenopalatine
External carotid in last resort
21
Q
What can be done to vessel if not ligated?
A
Embolised
22
Q
Why can anterior ethmoid not be embolised?
A
It comes from internal carotid artery
23
Q
How does cautery differ for anterior vs posterior?
A
anterior use rhinoscopy
Posterior use rigid endoscopy
24
Q
What is required following nose bleed?
A
2 day stay if had tampons
Neseptin (Abx + disinfectant) cream BD for 1 week
25
What imaging is used and what is looked for when foreign body is suspected to be in ENT?
Lateral neck x ray looking for soft tissue swelling as cannot see most foreign bodies
26
What is given if foreign body in oesophagus to help with vomiting?
IV buscipan
| Hyoscine bromide
27
Give two complications of fractures of nasal bones?
septal haematoma leading to saddle nose deformity
| Cerebrospinal fluid leak
28
How does a fracture of the nose lead to CSF leak?
Damage to dura due to trauma and fracture to base of skull
29
How can csf pooling and increasing pressure in skull be prevented?
lumbar drain
30
Give 3 things that can lead to saddle nose deformity?
Trauma damages septal cartilage leading to collapse of bridge
Septal haematoma prevents blood supply to septum leading to avascular necrosis and collapse of bridge
Cocaine leads to septal necrosis and saddle deformity and vasoconstricts blood vessels
31
Why is it important to surgically treat saddle nose deformity?
May affect breathing
32
What surgery treats saddle nose deformity?
Augmentation rhinoplasty
33
When there has been nasal trauma, how do we inspect for septal haematoma?
Otoscope or nasal speculum
34
When can nasal deviation due to fracture be manipulated under anaesthetic?
immediately or upto 2 weeks after
35
What management is required in septal haematoma?
immediate incision and drainage or wide bore needle aspiration to prevent ischaemia and necrosis
36
In the presentation of a neck lump, starting peripherally, what do you look for in patient?
any hoarse voice?
signs thyroid disease looking generally and at hands
Test reflexes/percuss sternum/look for pretibial myxemema
37
What could hoarse voice indicate?
Vocal cord pathology
| Invasive thyroid cancer/cancer lung
38
How do you examine the neck if lump?
Feel anterior and posterior triangles
Feel all lymph nodes
Feel parotid and submandibular salivary glands for swelling
Watch patient swallow water
Feel lump
Auscultate lump
39
What is the likely cause of midline lump?
Thyroid origin
40
What is the likely cause of off centre lump?
Branchial cyst
41
What is the likely cause of higher lump around mandible?
Tumours of salivary glands
42
What is the likely cause of multiple lumps?
Lymph nodes
43
What is required if you suspect lymph node pathology?
Feel for enlarged spleen or liver
| Look for dermatological cancers
44
Which lymph nodes do you dermatological cancers spread to?
cervical
45
How do you examine suspected malignant, submandibular salivary glands?
Bimanual palpation of submandibular gland, index finger in floor of mouth and ballot gland with other hand
46
Why do you ask patient to cough when examining oral cavity?
if cough bovine suggests vagus nerve problem
47
How may malignant submandibular glands feel?
They should feel hard and tethered
48
What is done if parotid gland swelling?
Check the function of the facial nerve as may be compressed by parotid tumour
49
What could tender lumps suggest?
Infection/abscess- ludwigs angina (rare skin infection on floor of mouth), parapharyngeal abscess, salivary gland infection
50
What will be characteristics on exam of cysts?
Mobile and fluctuant
51
What could be cause of mobile and fluctuant lump in children?
Cystic hygroma (lymph)
52
What are 2 causes for pulsatile masses?
carotid body tumour
| Aneurysm
53
What are superficial lumps vs deep lumps more likely to be? Benign/malignant
Malignant
54
What is involved in looking inside patients mouth?
Look in and then under tongue
| Get patient to say ahh to see if palate and uvula move normally
55
What indicates a cranial nerve 9/glossopharyngeal palsy?
Solt palette hangs lower on affected side
56
What indicates a cranial nerve 10/vagus palsy?
Uvula dangles more on one side
| The palsy is on the side it leans away from
57
What indicates a cranial nerve 12/hypoglossal palsy?
Tongue deviation toward side of palsy and muscle wastage on opposite side
58
What other abnormalities may be seen in mouth?
Ulceration
infection- abscesses or white spotting
Dryness
Tonsillitis
59
What infections may be looked for in mouth?
pharyngitis
Tonsillitis
Tonsillar abscess
60
What may swellings indicate?
Salivary gland pathology
61
What can be used to look harder at throat?
fibrooptic laryngoscopy
62
What is assessed with fibreoptic laryngoscope?
Vocal cords, swellings, lesions or nodules
| Ask patient to phonate and watch if vocal cords move normality
63
What can be used to get better look at how vocal cords move?
Videostroboscopy- looking under strobe light
64
What is a retropharyngeal abscess?
Infection of retropharyngeal space between pharynx and prevertebral fascia
Space extends from base of skull to mediastinum
65
What are signs and symptoms of retropharyngeal abscess?
```
occurs after upper resp tract infection
Neck held rigidly and wont move it
Systemically unwell
Airways compromise
Dysphagia
Young children
```
66
Why may patients get a heart problem and which one?
Pericarditis due to mediastinum communication
67
How will you investigate retropharyngeal abscess?
X ray shows widened retropharyngeal space
CT neck scan differentiates from cellulitis
Bloods for infection
68
What management is required for retropharyngeal abscess?
A-E
IV fluids and nutrition if required
Incision and drainage under anaesthetic
IV empirical anti bx
69
What is ludwigs angina?
Infection of submandibular space, between floor or mouth and mylohyoid muscle
70
What are signs/symptoms of ludwigs angina?
```
Difficulty breathing
Dysphagia
Drooling
Unusual speech
Tongue swelling nad protrusion
Fever and systemic symptoms of infection
Neck swelling and pain
Red neck
```
71
How do you investigate ludwigs angina?
```
Examine neck
CT neck
Orthopantogram- dental x ray
Fine needle aspiration- rule out infection/cancer
Blood cultures- rule out infection
```
72
How is ludwigs angina managed?
A-E
IV co-amoxiclav
Drain abscesses
73
Where is parapharyngeal abscess?
Infection of potential space postero-lateral to oropharynx and nasopharynx
74
What are signs and symptoms of parapharyngeal abscess?
```
Fever
Upper resp tract obstruction
Sore throat, dysphagia
Swollen neck above hyoid
Reduced neck movement
Jaw spasm
```
75
How is it investigated?
CT head
| Aspirate for culture
76
How is parapharyngeal abscess managed?
A-E
IV anti bx
Surgical drainage
77
What is the likely cause of a child aged 2-6, presenting with dysphagia, drooling and distress?
Epiglottitis
78
What is epiglottitis? causative?
Infection of epiglottis caused by H influenza
79
What other signs/symptoms may the child present with?
```
Stridor
Pyrexia
Neck tenderness over hyoid bone
Leaning forward with outstretched arms to more inflamed structures forward- TRIPOD SIGN
Refusing to lie down
```
80
What investigations are required?
urgent referral for laryngoscopy
Throat swabs when airway secure
Blood cultures if sirs signs
CT or MRI for formation of abscess
81
How is epiglottitis managed?
A-E
IV ceftriaxone
Paracetaomol
82
How will a pharyngeal pouch present?
```
Dysphagia
Regurging non digested food
Aspiration
Chronic cough
Weight loss
Lump in neck
Bad breath
```
83
What may happen to lump in neck on palpation?
Gurgles
84
What is a pharyngeal pough?
diverticulum forming between the thyropharyngeus and cricopharyngus muscles through killians dehiscence
85
How is a diagnosis confirmed?
barium swallow shows collection in pouch
86
What is the treatment options for small pouches?
Endoscopic stapling
87
What are 2 treatment optioins for larger pouches?
Diverticulectomy for large pouches- closes defect in muscle wall
Cricopharyngeal myotomy
88
Describe how a viral sore throat would look?
Red uvula, back of throat
| Bacterial has white exudates and enlarged tonsils
89
What is a quinsy?
```
Peritonisillar abscess (one enlarged tonsil) which forms from tonsil to wall of throat
May deviate uvula
```
90
How will quinsy present without opening patients mouth?
Swelling may be visible below mandible
| Hot potato voice
91
What may you see when open mouth?
Mouth cannot open very wide
Deviated uvula
Unilateral swelling of tonsil and exudate
May be palate swelling
92
What management is required for quinsy?
Ent emergency- steroids, needle aspiration, Pen V
93
What scoring system can distinguish between viral and bacterial sore throat?
Centor criteria
94
What makes up the centor criteria?
```
Temp >38
Exudate on tonsils or swelling
Absence of cough
Swollen anterior cervical lymph nodes
Age 3-14 (1)
15-44 0
>45 -1
```
2-3 culture and abx after
4+ rapid culture and abx`
95
What antibiotic treatment is given for tonsillitis?
Penicillin V
96
What antibiotic treatment is given for penicillin allergy for tonsillitis?
Erythromycin
97
What are the red flags for a cough?
```
Dyspnea
>3 weeks
Haemoptysis
Unintentional weight loss
Recurrent chest infection
Pleuritic chest pain
```
98
When is tonsillitis managed in hospital as day case?
If unable to swallow/eat
99
What is given to all tonsillitis patients in hospital?
PR diclofenac
Pen V IV
Dexamethasone IV
Diflam mouth wash (NSAID)
100
What is given for chest infections usually? With copd?
Amoxiclav
| Doxy and prednisolone
101
What management is required for pertusis? (whooping cough)
Inform public health england
| No antibiotics
102
How is EBV spread?
close/intimate contact and sharing cooking utensils, toothbrushes
103
How does it present?
```
Tonsillitis
Bilateral swollen lymph glands
Flu like symptoms
Swelling around eyes
Splenomegaly
```
104
sore throat, unwell and no enlarged tonsils what should be suspected?
Epiglottitis
105
How is glandular fever confirmed?
blood tests show atypical lymphocytes which resemble monocytes
Monospot test for heterophile antibody which is produced
106
What treatment is offered?
```
None
Usually analgesi
Fluids
prevent spread
avoid contact sports for 8 weeks as need to avoid trauma to spleen as risk of rupture
```
107
What drug must you never give if you suspect EBV? DDX for issue
Amoxicillin Macula erythematous rash 5-9 days after treatment
Penicillin allergy rash
It is more tan/brown in colour
108
In which patients should you suspect head and neck cancer in? symptoms
```
Dysphonia
Dysphagia
Dyspnoea- stridor
Neck mass
Pain and referred pain to ear
Recurrent bleeding for nose/mouth with no trauma
nasal blockage
```
109
What cell type is the cause of the majority of head and neck cancers?
Squamous
110
Risk factors? ca
Smoking/chewing tobacco
Alcohol
Chinese people
Betel nut chewing (SCC mouth and oesophagus)
111
How do you investigate head and neck cancer
Examine under anaesthetis- ultrasound guided fine needle aspiration biopsy of site
Ct head and neck
CT CAP for distant metastases
112
Why use fine needle over incisional?
incisional more likely to cause spread of malignancy
113
What treatment can be offered for head and neck cancer to cure it?
Radiotherapy to primary site and neck
Chemotherapy
Endoscopic laser resection surgery
Open surgery to removal lymph nodes of larynx
114
Which salivary gland is most commonly the cause of a salivary gland tumour?
parotid- 80 percent benign
115
WHat sort of tumour is most common in parotid gland?
Pleomorphic adenoma
116
What are risk factors for salivary gland tumours?
smoking
| Radiation to neck
117
How may a patient with salivary gland tumours present?
Slow enlarging painless mass
| Hardness/fixation/tender/overlying skin ulceration
118
How do parotid, submandibular and sublingual tumours growth differ?
Parotid- discrete mass at tail of gland
Submandibular diffuse enlargement
Siblingual- fullness at floor of mouth which may be palpable and affect speech
119
What are red flags for salivary gland tumours?
facial weakness (facial nerve passes through parotid gland)
Rapid increase in lump size
Ulceration
Paraesthesia or anaesthesia of face
Intermittent pain
History of skin cancer/sjogrens/radiation to head and neck
120
How are salivary gland tumours investigated?
Ultrasound guided fine needle aspiration
| CT scan for deep tissue extension and evaluate tumour size
121
What extra imaging is required in sublingual tumour and why?
MRI for sublingual tumour as risk of malignancy is high
122
How are salivary gland tumours managed?
Local ablation
Radiotherapy after surgery
Superficial parotidectomy sparing facial nerve
123
Which salivary gland tumour requires complete excision
Submandibular
124
What are the red flags for a patient with hoarse voise?
| >3 weeks
```
>3 weeks
Dysphagia
Haemoptysis
Otalgia
Unexplained weight loss
History or excessive alcohol intake
Smoking history
```
125
What may a hoarse voice with red flags indicate?
squamous cell carcinoma of the larynx or lung tumour
126
Give other causes for hoarseness?
```
Laryngitis
GORD
Benign vocal cord nodules/cysts/polyps
Smoking
Allergies
Neurological conditions
Cancer- left sided lyng/larynx/vocal cord
Overuse of vocal cords
```
127
What investigations can be done vocal cords
Chest x ray if hoarseness lasted >3 weeks
Imaging to look at throat/vocal cords
Fine needle aspirate biopsy for suspected cancer
CT/MRI for malignancies and nerve damage
128
What treatments can be given?
Depends on cause above!
| Surgery to remove cancers/persistant benign masses
129
What is round and oval window
2 openeings to inner ear.
| Round window for allow cochlea to move
130
What is it important to check for with lacerations to ear?
Check any exposed cartilage is covered with skin as may require plastics
131
How are bite wounds managed?
Leave wound open
| Wound irrigation and antibiotics
132
Where does haematoma form?
Within pinna
133
How does this haematoma create cauliflower ear?
May lead to disruption of blood supply to cartlidge
This leads to AVN
Scar tissue forms and creates cauliflower ear
134
What can be used to prevent this?
Drainage and pressure dressings to prevent re-accumilation
135
What is otitis externa?
inflammation of the skinof the external acoustic meatus and pinna
136
What bugs AOE
Pseudomonas aureginosa
Staphylococcus aureus
fungi
137
Who do you take swabs with in AOE?
Those that do not get better following antibiotics
138
What is a distinguishing feature of otitus externa on examination?
Severe pain when touching pinna
139
What features of the history suggest otitis externa?
```
Swimming/recent putting things in ears
Itchy ear
Kids tug at ear
Discharge from ear
Hearing muffled
```
140
What management can be used in most cases otitis externa?
Topic ear drops empirically e.g. gentamycin
| Microsuction pus/debris enabling drops to get to source of infection
141
What management can be used in severe cases of otitis externa?
Wick to hold canal open and let topoical treatment through
142
If not treating empirically what options may be used?
Fungal infection with topical antifungals
| Specific antibiotics
143
How would you advise a patient with AOE on prevention?
Avoid excessive cleaning and depletes wax
Avoid ear plugs/ear phones
Avoid bathing/swimming
144
What antibiotic choice is used in event of tympanic rupture?
Ofloxacin
145
How do you treat severe ear wax?
Syringe
| 5 days olive oil before this
146
Give 2 complications of otitis externa in those who are immunocompromised?
Meningitis in diabetics/immunocompromised
| osteomylelitis
147
How can infection lead to osteomyelitis and nerve damage?
Spreads t mastoid and temporal bones
148
How may these patients present?
Headache, intense ear pain out of proportion to appearance of disease
Facial nerve palsy is red flag
Exudate
Swelling of ear
149
How would malignant otitis externa be managed differently?
Urgent ent referral and admit for iV anti biotics
Technetium bone scan to look for osteomyelitis
CT to view full extent of disease
May require debridement of some affected bony structures
150
What can cold water swimming cause in ear?
Osteoma
151
What is the prognosis of osteoma?
hard swelling but no complications
152
What hearing loss may those with perforations present? Osteoma
- Conductive hearing loss
153
How will webers and rinnes test show conductive hearing loss with tympanic membrane perforation?
Lateralise to affected ear
| BC> AC in affected ear
154
What can cause perforations?
Trauma
Otitis media
Drugs
155
What will perforation present with?
Pain
| Possible conductive hearing loss
156
Trauma may cause conductive hearing loss by rupturing the tympanic membrane, how can trauma cause sensorineural hearing loss?
Base of skull fracture
157
How are perforations managed?
usually heal themselves
Care with washing in future
Ear plugs with swimming
Care with ear drops
158
When is surgery required for perforations?
not healed within 6 months
159
What is this surgery called?
Myringoplasty
160
What is a haemotympanum?
Blood in the middle ear which is seen through the tympanic membrane
161
How will haemotympanum present?
Conductive hearing loss
162
What is often associated with haemotympanum?
Temporal bone fracture
163
How is haemotympanum managed?
Conservative treatment until resolves then testing for residual hearing loss as Ossicles may be damaged
164
What is cause of red ear/vascular ear with intact ear drum that is pulsatile?
Glomus tumour - benign
165
What are the two types of otitis media?
Actue and chronic
166
What are the two types of chronic otitis media?
mucosal and squamous
167
What are the two types of squamous and mucosal?
active and inactive
168
What are the most common causes of AOM? bugz
Strep pneumonia
H. influenza
Moraxella species
169
When may AOM occur?
Following infection of mouth or throat
170
What could be the cause of progressive deafness in a patient with family history of hearing loss?
Otosclerosis (abnormal growth and remodelling of ossicles)
Autosomal dominent
unable to transmit vibrations easily
171
What symptoms would you ask about?
Progressive deafness
Tinnitus
Imporved hearing in noisy locations early in disease
Fam history- autosomal dominant
172
How can otosclerosis be diagnosed?
Pure tone audiogram shows conductive eharing loss with a characteristic Carhart notch at 2kHz on bone conduction
Initially unilat so one ear better than other
173
What is schwartzes sign?
Pink tympanic membrane- although most will be normal
174
What will tympanogram show? otosclerosis
Normal
175
How can otosclerosis be treated following diagnosis via pure tone audiogram?
Most- Hearing aid
| Some- Stapdectomy (free stapedius from oval window and replace with prosthetic stapedius)
176
What is vertigo?
sensation of movement when stationary
| Patient says they feel as if room is spinning/unsteady/NV
177
Give causes for dizziness, faintness, unsteadiness without hallucination of movement?
```
Cvs causes
Medication
Anaemia
Sensory neuropathy
Alcohol intoxication
anxiety
```
178
Give CVS causes for dizziness?
Postural hypotension
Cardiac arrhythmias
Heart failure
IHD
179
What is the most common cause of vertigo?
multifactorial desequilibration of aging
180
What factors majorly increase the risk of deqequilibrium of aging so must be asked in history?
Smoking – hardens the vessels to decrease blood supply
Type 2 diabetes- problems with proprioception
Anti hypertensives- decrease ability to respond to decrease in BP
Vision problems
181
How deqequilibrium of aging above managed?
Reduce risks of falling- send to falls clinic
| Remove risk factors if possible
182
What are the two groups of causes for vertigo? Where are each of the causes?
Central and peripheral
Central- cerebellum or brainstem
Peripheral- inner ear
183
Give central causes of vertigo?
```
Stroke
Migraine
Drugs
SOL
Demyelineation like MS
```
184
Give peripheral causes of vertigo?
```
BPPV
Menieres disease
Labyrinthitis
Vestibular neuritis
Acoustic neuroma
```
185
How can you test to see if it is a central or peripheral problem?
Central- positive rombergs sign, heel to toe walking test difficult
Peripheral- positive unterbergers stepping test, Dix-Hallpike manouvre
186
What are the differences in the history that may distinguish central from peripheral vertigo?
Central- worse balance, positive neurological symptoms, lack of auditory symptoms, gradual onset
Peripheral- auditory symptomsm likely, often acute onset, more nystagmus
187
What is the only cause of vertigo to come on with movement of the head?
BPPV
| Tends to come on while lying in bed
188
Time frame BPPV Menieres Labrynthitis
Seconds-minutes hours Hours-days
189
Trigger BPPV Menieres Labrynthitis
Head movement-
| Can follow ear infection or head injury clusters continous
190
Cause BPPV Menieres Labrynthitis
Idiopathic crystals of calcium carbonate entering semi circular canals in vestibular apparatus in inner ear- usually posterior semi circular canal. They move and stimulate sensory epithelium in canals and send impulse to brainstem. Build up of fluid in labyrinth Viral infection precedes symptoms
191
Assocaited sympotomsBPPV Menieres Labrynthitis
```
NV
No tinnitus/hearing loss NV
Tinnitus
Hearing loss NV
Tinnitus
Hearing loss
```
192
What is the cardinal trigger for BPPV?
Rolling over in bed
193
Describe a test for benign paroxysmal positional vertigo?
Hallpike’s test turn patients head to one side 45 degrees and lie patient down quickly, observe patients eye movements for rotational nystagmus, ask if patient feels dizzy/vomits/nauseous
194
Which ear is affected in BPPV in epley manoeuvre?
Ear which is undermost
195
How can you manage BPPV in stepwise fashion?
Usually self limintg 1-2 weeks
If persistant.. Epley manoeuvre to move causative crystal round the canal and out of the canal opening
If still not better.. Operation which plugs semi circular canals to prevent crystals entering canals
196
hat treatment and management is required for meneires disease?
What treatment and management is required for meneires disease?
Veritgo may resolve in 10 years as other eye compensates- but balance will remain poor
Dietary management- reduce salt, chocolcate, alcohol, caffeine,
Medical - Thiazides
Betahistine (anti vertigo)
Vestibular sedatives- prochlorperazine
```
Surgical - Grommet insertion
Middle ear dexamethasone injection
Endolymph sac decompression
Vestibular destruction with gentamycin- deaf after
Surgical labyrinrhectomy
```
197
What is the cause of menieres disease?
Abnormal sodium channels in canals cause increased fluid in the endolymph compartment of the membranous labyrinth responsible for regulating balance
This fluid increasing creates menieres attack and when the pressure builds to a point there is then rupture and then the fluid level drops again
198
How does menieres disease present?
```
Tinnitus in affected ear
Vertigo minutes to hours
NV with vertigo
Fluctutating sensoriheural hearing loss
Aural fullness
diarrhea
```
199
What is diagnostic for menieres disease?
Low to medium frequency Sensorineural hearing loss
Rotational vertigo
Tinnitus
200
What symptom almost makes a diagnosis of menieres certain?
Diarrhea
201
How does meneires disease differ from vestibular migraine?
Migraine has no hearing loss usually and imbalance rather than true vertigo
202
What is the prognosis of menieres disease?
Gradual loss of hearing if not treated
203
What may follow an acute attack of menieres?
a few days of hearing/balance off due to temp damage to cilia from increased fluid
204
What is labyrinthitis?
Inflammation of inner ear and/or vestibular nerve leading to days of vertigo with NV
Permanent hearing loss
Tinnitus
205
How is vestibular neuritis different to labyrinthitis?
It is just vestibular nerve affected
| No hearing loss/tinniturs
206
What features of patient history suggests vestibular neuronitis?
```
URTI precedes it
Horizontal nystagmus in attack
NV and sometimes diarrea
No hearing loss/tinnitus
Vertigo worsened by movement
```
207
What can vestibular neuritis lead to?
BPPV
208
When will there be sensorineural hearing loss in labyrinthitis?
If cochlear is affected
209
How can labyrinthitis be investigated?
FBC and blood cultures if infective cause suspected
CT to rule out mastoiditis
MRI for MS
Hearing tests
210
How is labyrinthitis treated?
Vestibular sedatives (prochlorperazine) and anti vertigo drugs (betahistine)
Balance treated by Cawthorne-Cooksey exercises
Metoclopomide for anti emetic
211
How may the vestibular neuronitis affect the patient in weeks after
Generalised unsteadiness
212
Give 5 groups of causes for tinnitus? examples of each
Otological presbyacusis, otosclerosis, ear infection, menieres disease
Neurological head injury, MS, acoustic neuroma
Infectious syphilis, meningitis
Drugs salicylates, NSAIDs, aminoglycosides, loop diuretics, cytotoxicity
Jaw disorder temporomandibular joint dysjunction
213
How do you examine tinnitus?
Examine ENT, jaw and head
Audiometry
CT/ MRI if audiometry shos hearing loss
214
How is tinnitus managed?
treat cause
relieve stress
Retraining therapies
Masking devices
215
WHat symptoms to patients with vestibular migraine present with?
```
Imbalance/occasionally true rotational sensation
Vomiting, sensitivity to light and sound
Headache may be present
No hearing loss
May have tinnitus
```
216
Give possible factors that could cause vestibular migraine?
May be linked to food or hormones in menstruation
| Patient usually have travel sickness history
217
Describe a test which tells us there is a problem with balance due to proprioception or vestibular system vs eyes?
Rombergs test- ft together, close eyes and look for swaying
218
How can we distinguish between vestibular and proprioception being the cause for the balance problem?
Unterberger’s test- march on spot with arms outstretched and eyes closed. Patient will turn towards affected side (30 degrees rotation within 50 steps)
219
What is the diagnostic meaning of sudden onset hearing loss?
Loss of hearing of 30+dB over 72 hours
220
What is the investigations required? sudden hearing loss
ontological emergency!!
Sensorineural or conductive tests? Rinners or pure tone audiogram
MRI or CT if MRI not possible
221
What is the use of MRI? suddent hearing loss
Looking for lesions or compression along central auditory pathway such as acoustic neuroma
222
What management is required? sudden hearing loss
Steroids infected into middle ear or oral
| Anti virals if viral cause
223
What is the prognosis of sudden onset hearing loss?
1/3 recover fully
1/3 have some recovery
1/3 stay completely deaf
224
What is meant by acoustic neuroma?
Tumour of schwann cells surrounds 8th cranial nerve- vestibule cochlear
225
How may a patient present with an acoustic neuroma?
```
Unilateral hearing loss progressive
Tinnitus
Impaired facial sensation or pain - trigemminal nerve
Balance problems/vertigo
Ear ache
Ataxia -Cerebella compression
```
226
Which part of nerve is more affected usually and how does this affect presentation?
Cochlea portion, hearing more than balance
227
What are risk factors for this USUALLY BENIGN tumour?
neurofibromatosis
| Radiation
228
How do you investigate acoustic neuroma?
audiology- sensorineural hearing loss
| MRI
229
How do you treat acoustic neuroma?
Microsurgery or sterotactic radiosurgery
| Monitor growth until surgery more easily achieved
230
WHat foods contain magnesium?
Leafy greens, fish, nuts
231
What is the problem with measuring serum magnesium?
It correlates poorly with total body magnesium
232
DDX CSF and mucus?
beta-2 transferrin
233
What do you look for on general inspection?
Asymmetry
Skin scars/signs radiotherapy
Lumps/bumps/muscle wastage
Eye alignment
234
What are scars to look out for?
Incision near nose- open rhinoplasty
Scar between tragus and helix- myringoplasty
Scar behind ear- post auricular approach for myringoplasty
Neck scars- thyroglossal cyst/ thyroidectomy
235
what could be a non worrying cause of enlargement of post auricular lymph node?
Dandruff
236
What do you do when hands get to jaw?
Test jaw opening for TMJ dysfunction/pain
237
What important landmarks are found at C6?
Cricoid cartilage
Start of oesophagus
Larynx turns into trachea
238
Where does accessory nerve lie in relation to SCM?
1/3 way down from top of SCM
239
What is found in the anterior triangle?
```
7
9
10
11
12
Common carotid artery which bifurcates
Internal jugular vein
Suprahyoid muscles
Infrahyoid muscles
```
240
Name the suprahyoid muscles?
geniohyoid
Digrastric
mylohyoid
stylohyoid
241
Name the infrahyoid muscles?
Omohyoid
Thyrohyoid
Sternohyoid
sternothyroid
242
fUNCTION of neck muscles
Elevate hyoid (initiate swallowing)
Depress hyoid/ thyroid cartialage
243
Lymph node levels of neck zone1
Submental nodes Submandibular nodes
| Mandible to hyoid, posterior is digastric
244
Lymph node levels of neck zone2
Upper internal jugular (deep cervical) nodes
Superiorly: Skull base
Inferiorly: Inferior border of hyoid bone and Carotid bifurcation
Posteriorly: Posterior border of Sternocleidomastoid (SCM)
Anteriorly: Lateral border of Sternohyoid and Stylohyoid
245
Lymph node levels of neck zone3
Mid internal jugular (deep cervical) nodes
Superiorly: Inferior border of hyoid bone and Carotid bifurcation
Inferiorly: Inferior border of cricoid cartilage and Junction of omohyoid muscle and IJV
Posteriorly: Posterior border of SCM
Anteriorly: Lateral border of sternohyoid
246
Lymph node levels of neck zone4
Lower internal jugular (deep cervical nodes)
Superiorly: Inferior border of cricoids cartilage and Junction of omohyoid and IJV
Inferiorly: Clavicle
Posteriorly: Posterior border of SCM
Anteriorly: Lateral border of sternohyoid
247
Lymph node levels of neck zone5
Posterior triangle (spinal accessory) nodes
Superiorly: Convergence of SCM and trapezius
Inferiorly: Clavicle
Posteriorly: Anterior border of trapezius
Anteriorly: Posterior border of SCM
248
Lymph node levels of neck zone6
Anterior compartment (midline) nodes
Superiorly: Hyoid bone, Inferiorly: Suprasternal notch, Bilaterally: Carotid arteries
249
Lymph node levels of neck zone7
Upper mediastinal nodes
Below suprasternal notch
250
Give specific topics to be covered whilst taking the history of someone with an ear infection?
```
Symptoms- deafness, pain, vertigo, discharge, tinnitus
Ear surgery/ head injury
Fam hx
Systemic disease
Ototoxic drugs
Occupational exposure to noise
Allergies/atopy
```
251
What will be looked for on inspection of external ear?
```
Inflammation
Lesions
Scars
Congenital abnormalities
Discharge/wax
Sinus/tags
Skin conditions like eczema
```
252
What should be visible on looking at tympanic membrane?
Umbo sed part of membrane where handle of malleus attaches)
| Handle of malleus
253
Why look in attic? (behind pars flaccida)
Here is where cholestetoma will be found. If any perforation this is an emergency
254
How may an abnormal tympanic membrane appear?
Red, shiny, bulging or retracted
| No cone of light reflection
255
Holes in spenoid bone
Orbital canal
Superior and inferior orbital fissure
Sphenoid
256
6th nerve palsy danger?
Bilateral 6th nerve palsy is genuine raised intracranial pressure due to long tortuous course of abducens nerve
257
Layers of eye
Outer fibrous- sclera and cornea
Middle vascular- choroid, ciliary body, iris
Inner layer- retina
258
What is the largest vascular layer of the eyeball? What does it terminate as?
Choroid- dark membrane between sclera and retina
| Ciliary body
259
What are the roles of the ciliary body?
Secrete aqueous humor into posterior chamber of eye.. then flows out to anterior chamber and out of trabeculae in anterior chambr
Contraction of muscle fibres in the ciliary body changes the shape of the lens to allow focusing of close objects
260
If the fluid in the chambers flow is obstructed, what clinical condition occurs? What are the two types of glaucoma?
Glaucoma as intraocular pressure rises and causes damage to optic nerve
• Open angle – Where the outflow of aqueous humor through the trabecular meshwork is reduced. It causes a gradual reduction of the peripheral vision, until the end stages of the disease.
• Closed angle – Where the iris is forced against the trabecular meshwork, preventing any drainage of aqueous humor. It is a ophthalmic emergency, which can rapidly lead to blindness
261
What is the iris and what two muscles control its pupil?
Thin contractile diaphragm with pupil in middle for transmission of light
Sphinctor and dilator pupillae
262
What supports the lens and holds the retina in place? Where is it found
Vitreous humour
| Posterior segment- everything behind lens,
263
What are the two layers of the optic retina?
Neural - consists of photoreceptors
| Pigmental- supports neural layer
264
Describe the route lacrimal fluid takes when secreted from the lacrimal gland to the lacrimal sac?
Describe the route lacrimal fluid takes when secreted from the lacrimal gland to the lacrimal sac?
Enters conjunctival sac through lacrimal ducts and passes into lacrimal lake at medial angle of the eye then drans into lacrimal sac
Nasal cavity via nasolacrimal duct and into inferior meatus to be swallowed in nasopharynx
265
What lines the inner surface of the eyelids?
Palpebral conjunctiva
266
Where is the bublar conjunctiva found?
Lines the surface of the eye except the iris
267
What strengthens the eyelids and what is another role of these things?
```
Tarsal plates (dense bands of connective tissue)
Contain tarsal glands, secretion lubricates eyelides and prevents them from sticking together when they close
```
268
What is the inflammation of a tarsal gland called? How is this defferent to stye?
Chalazion/meibomian Cyst
Cyst within sebaceous gland
A chalazion is caused by noninfectious meibomian gland occlusion, whereas a stye usually is caused by infection
With time, a chalazion becomes a small nontender nodule in the eyelid center, whereas a hordeolum remains painful and localizes to an eyelid margin
269
Who is more at risk of forming chalazion cyst or styes?
acne
Rosacea
Seborrheic dermatitis
Blepharitis – inflammation of eyelid
270
How are chalazion cysts and styes managed?
Lid hygene- warm. Compress and clean
Surgery to remove non-resolving chalazions if lid hygiene doesn't work or steroid injection (not stye)
Eyelash may be plucked for stye
271
What is a blowout fracture of the orbital? How does is cause sustained looking downwards?
Indirect trauma or injury displaces orbital contents into maxillary sinus TEAR DROP SIGN
inferior rectus muscle becomes trapped and sustained contraction results in patient looking downwards
272
How is blowout fracture investigated?
X ray or CT of orbit to rule out other trauma
273
When is surgical repair required? blowout fracture
Pain on movement of eye or double vision
274
What should patients with small fractures be careful about and how may they be managed?
don't blow nose
| Steroids and decongestants to help drainage of blood and fluid from sinuses to reduce inflammation
275
What can you look for in blow out fracture?
Numbness in cheek, upper lip and gum – maxillary brancg
| Inability to move eye ball up or down – CN3
276
What is retinal detachment? How can it be treated and prognosis?
Retina neural and pigmented layers separate due to severe blow, stitch back to choroid but may cause blindness in that eye if not treated quick enough
277
What are the 3 groups of causes of retinal detachment?
Rheumatogenous
Exudative
Tractional
278
What is meant by rheumatogenous retinal detachment?
Vitreous gets older and contracts to cause posterior vitreous detachment
Adhesions form between vitreous and retina leading to tears
Liquefied vitreous humour infiltrates through tear and widens the potential space between sensory retina and pigment epithelium
279
What causes exudative retinal detachment?
Inflammation
Hypertension
Malignancies
280
How do these conditions cause retinal detachment?
increase permeability in vessels of choroid layer and fluid leakage into subretinal space leads to detachment
281
What is meant by tractional retinal detachment?
Scar tissue forms which leads to separation of retina from choroid, caused by diabetic and hypertensive retinopathy
282
What are risk factors for retinal detachment?
```
age
Extreme myopia – longer eye?
Fam hx or past hx
Trauma
Prev cataract surgery
Diabetes or htn
Malignancy
Inflammatory eye disease
```
283
What are the Fs which are the signs and symptoms of retinal detachment?
flashing lights - photopsia
Floaters
Visual field defects
Fall in acuity
284
What is different about the curtain closure in retinal detachment vs strokes/TIA?
Curtain stays when eyes move in retinal detachment
| Curtains moving with the eye is stroke/TIA
285
What confirms retinal detachment in examination?
visual field defects
Reduced visual acuity may or may not be present
Fundoscopy shows retinal tear
286
What investigations can be done retinal detachment
Ultrasound
| Optical coherence tomography
287
How is retinal detachment managed?
How is retinal detachment managed?
Same day ophthalmology review
Laser surgery for reinal tears without or with small setachment
Surgery for detachment
Vitreous removal
Gas or silicone bubbles may be injected into the globe to put pressure on retina to flatten it back down
288
What may be done in exudate causes?
Exudative causes treat cause
289
What is the most likely cause of choroiditis?
Infection in immunocompromised patients
Also be TB or lyme in non-immuno comp
or autoimmune
290
What facial rash is associated with sarcoidosis?
lupus pernio- raised purple plaque of indurated skin around the nose
