ENT + Ophthalmology Flashcards
1
Q
key features of acoustic neuroma
- vertigo
- tinnitus
- hearing loss
- nystagmus
- other
A
key features of acoustic neuroma
- vertigo - yes
- tinnitus - yes
- hearing loss - yes, sensorineural
- nystagmus - yes
- other - absent corneal reflex
dizzy, ringing, deaf, beating eyes
usually unilateral, if bilateral consider NF2
2
Q
key features of benign paroxysmal positional vertigo
- vertigo
- tinnitus
- hearing loss
- nystagmus
- other
A
key features of benign paroxysmal positional vertigo
- vertigo - yes
- tinnitus - no
- hearing loss - no
- nystagmus - yes
- other
- N&V
- Dix Hallpike positive
- episodic, triggered by movement, resolves on keeping still
3
Q
key features of cholesteatoma
- vertigo
- tinnitus
- hearing loss
- nystagmus
- other
A
key features of cholesteatoma
- vertigo - no
- tinnitus - no
- hearing loss - yes, conductive
- nystagmus - no
- other
- painless
- foul smelling otorrhoea
4
Q
key features of meniere’s
- vertigo
- tinnitus
- hearing loss
- nystagmus
- other
A
key features of meniere’s
- vertigo - yes
- tinnitus - yes
- hearing loss - yes, sensorineural
- nystagmus - yes, horizontal
- other
- sense of ear fullness
- +ve Romberg test
- bilateral
- if unilateral must do MRI to exclude acoustic neuroma
5
Q
meniere’s vs acoustic neuroma
A
typically meniere’s is bilateral and acoustic neuroma is unilateral
exceptions apply but let’s not stress about that
6
Q
key features of otitis externa
- vertigo
- tinnitus
- hearing loss
- nystagmus
- other
A
key features of otitis externa
- vertigo - no
- tinnitus - no
- hearing loss - yes, conductive
- nystagmus - no
- other
- tender tragus
- ear pain, worse at night
- itch
7
Q
key features of otitis media
- vertigo
- tinnitus
- hearing loss
- nystagmus
- other
A
key features of otitis media
- vertigo - no
- tinnitus - no
- hearing loss - yes, conductive
- nystagmus - no
- other
- bulging tympanic member
- otorrhoea if membrane perforates, associated with sudden reduction in pain
8
Q
key features of vestibular neuritis
- vertigo
- tinnitus
- hearing loss
- nystagmus
- other
A
key features of vestibular neuritis
- vertigo - yes
- tinnitus - no
- hearing loss - no
- nystagmus - yes, horizontal
- other
- N&V
- gait instability → falls to affected side
- Hx of viral infection usually
- due to reactivation of latent HSV1 in vestibular ganglion
9
Q
key features of labyrinthitis
- vertigo
- tinnitus
- hearing loss
- nystagmus
- other
A
key features of labyrinthitis
- vertigo - yes
- tinnitus - yes
- hearing loss - yes, sensorineural
- nystagmus - no
- other
- Hx of URTI usually
10
Q
difference between vestibular neuritis vs acute labrythinthitis
A
- vestibular neuritis
- hearing is normal
- acute labyrinthitis
- hearing loss or tinnitus
- can be unilateral or bilateral
11
Q
definition of acoustic neurone + RF/aetiology
A
Tumours of the vestibulocochlear nerve (CN VIII) arising from the Schwann cells of the nerve sheath
- NF2 (AD) associated esp. with bilateral
- 8% of all intracranial tumours
- 80% from cerebellopontine angle
12
Q
Ix for acoustic neuroma
A
-
Bedside
- Otoscopy
- CN and cerebellar examination
- Bloods
-
Imaging
- MRI of inner ear apparatus - gadolinium enhanced is gold standard
-
Specialist or scoring
- Genetic screening for NF2 - only if early onset (younger than 20s)
- Audiology - 1st line if hearing impairment
13
Q
management of acoustic neuroma
A
-
Observation - can be offered as up to 75% show no growth
- Indicated for small neuromas with preserved hearing
- If growth is to occur usually In the first 3 years
- MRI every 6/12 for 2 years, then scan at 4 years after which every 5 years lifelong
-
Microsurgery - treatment of choice
- Complete removal is possible in most cases
- Approach determined by size, location and importance of hearing preservation
- Radiotherapy
14
Q
management of Bell’s palsy
A
- Prednisolone 50mg PO for 10 days + tapering
- Supportive management
- Artificial tears
- Ocular lubricants
- Eye patch/tape
- Aciclovir - only if cannot exclude Ramsey hunt syndrome (herpes zoster infection)
Indications for referral: worsening or new neurological findings; UMN cause; malignancy features, systemic or severe local infection, trauma, persists > 3/52, eye sx → ophthal r/v
15
Q
management of BPPV
A
- Lifestyle - reduce head movements, slowly get out of bed
-
Safety - assess safety e.g. shouldn’t drive when dizzy or driving triggers vertigo
- DVLA notification
- Occupational assessment
- Falls risk
-
Epley manoeuvre - reposition otoliths into utricles from the posterior semi-circular canals
- F/up in 4/52 to assess for resolution
- Surgery - last resort, denervating the posterior semi-circular canals or obliterating with laser, risk of hearing loss
16
Q
definition of cholesteatoma
A
Abnormal accumulation of squamous epithelium and keratinocytes within the middle ear or mastoid air cell spaces which can become infected and erode neighbouring structures
- not strictly malignant but is destructive
- untreated can be fatal as spread from middle ear up toward mastoid etc
17
Q
Ix and management of cholesteatoma
A
-
investigations
- Otoscope examination
- Audiology assessment
- CT scan – head
-
management
- Referral urgently to ENT
- Emergency admission if facial nerve palsy, vertigo or other neurological signs raising concern of intracranial abscess or meningitis
- Medical – topical antibiotics if purulent discharge/acute concurrent infection
- Surgical – removal
18
Q
what is the NICE recommended diagnostics for infectious monomucleosis
A
NICE recommends in 2nd week of illness to confirm diagnosis monospot + FBC
19
Q
Ix for infectious mononucleosis
A
- Diagnostic - NICE recommends in 2nd week of illness to confirm diagnosis monospot + FBC
-
Bedside
- Abdominal examination - hepatomegaly, splenomegaly
- Lymph nodes (cervical) - enlarged
-
Bloods
- FBC (atypical lymphocytosis)
- Blood film - > 10% atypical lymphocytes
- LFTs
- ESR
- Serology
-
Heterophile antibody “Paul Bunnell”/monospot test → +ve
- If negative or doesn’t support diagnosis, can re-test in 5-7 days
- Ideally done in 2nd week of illness
- EBV specific antibodies
- Indicated in those < 12 after at least 7 days of illness
-
Heterophile antibody “Paul Bunnell”/monospot test → +ve
-
Imaging
- Abdominal USS - assess for splenomegaly
20
Q
management of infectious mononucleosis
A
Supportive
- School exclusion recommended for children
- Rest
- Sufficient fluid intake
- Simple analgesia for aches and fever
- Avoid alcohol
- Avoid heavy lifting and contact sports for 4-8 weeks - ↓ risk of splenic rupture
Medical - steroid treatment if severe (airway obstruction from lymphadenopathy or haemolytic anaemia)
Do not give amoxicillin or ampicillin if suspected as can cause eruption of maculopapular pruritic rash
21
Q
what is meniere’s disease
A
Condition caused by dilatation of endolymphatic spaces of the membranous labyrinth causing episodes of vertigo lasting for 12-24 hours.
- Condition affecting the inner ear
- Vertigo + fluctuating hearing loss + tinnitus + sense of aural fullness
- over time tinnitus + hearing loss can become more severe + persistent, but vertigo improves
22
Q
investigations for meniere’s disease
A
-
Bedside
- Audiometry - sensorineural hearing loss, mid-to-low frequency
- CN examination
- Hallpike manoeuvre - exclude BPPV
- Otoscopy - examine tympanic membranes
-
Imaging
- MRI brain - advised in cases of unilateral disease
23
Q
management of meniere’s
A
- Referral to ENT - confirm diagnosis
-
Conservative
- Advise that attaches of vertigo usually settle within 24 hours
- No driving when dizzy
-
Medical
-
Prophylactic betahistine - ↓ frequency of attacks, 16mg orally TDS. Maintenance usually 24-48mg OD
- CI: phaeochromocytoma, asthma (relative), hx PUD (relative)
- PRN prochlorperazine - acute use, used as anti-emetic
-
Prophylactic betahistine - ↓ frequency of attacks, 16mg orally TDS. Maintenance usually 24-48mg OD
-
Severe symptoms: admission + IV labyrinthine sedatives + IV fluids for hydration maintenance
- Rapid relieve of severe N&V - buccal/IM prochlorperazine or Cyclizine
-
Surgical
- Poor evidence
- micro-pressure therapy (NICE, utilises grommet to blow air at low pressure into air)
24
Q
management of epistaxis
A
-
ANTERIOR
- compression for at least 10 minutes
- Lean forward + squeeze on soft part of nose (compress Little’s area)
- Cautery → used to seal
- Chemical (silver nitrate) or electrical (thermal)
- After care:
- Naseptin 10 days, topical
- compression for at least 10 minutes
-
POSTERIOR
- A-E, admit, refer to ENT emergently
- Nasal packing
- Rapid rhino (inflatable), balloon, BIPP ribbon gauze
- Trans-nasal endoscopy with direct cautery/arterial ligation - uncontrollable severe bleeding unamenable to packing
- Cautery only if can visualise vessel
- Saphenopalatine artery usually the artery ligated in emergent surgery
25
most common causes of otitis externa
* _Staphylococcus aureus_
* Over time will be replaced by Klebsiella, E. Coli, _Pseudomonas aeruginosa_
* **Pseudomonas** often seen in chronic or inadequately treated otitis externa
26
what is malignant otitis externa?
_Malignant otitis externa_ - "necrotising otitis", potentially life-threatening, progressive external ear canal infection which may cause osteomyelitis of temporal bone + other skull bones
27
management of acute otitis externa
**Mild-moderate**
1. **Topical antibiotics + steroid**
* Aminoglycosides e.g. gentamicin are very good cover for pseudomonas, but they are **ototoxic** if reaching the inner ear
* *_Do not give unless sure of tympanic membrane is intact_*
2. **Topical antifungals -** If fungal infection suspected
3. **General advice** - keep ear dry for 7-10 days
**Severe infection**
* **Suctioning by ENT**
* **Antibiotic impregnated ribbon gauze**
* ENT guided - ribbon gauze with Abx to allow for deeper application of topical antibiotics
* **Oral/IV antibiotics** - if osteomyelitis or abscess in post-auricular area/neck
* Indications: cellulitis beyond external ear canal, immunocompromised and severe infection/high risk, complete ear canal blockage so that ribbon gauze with topical antibiotics cannot be inserted
28
what are the complications of otitis externa
* Chronic otitis externa
* cellulitis
* osteomyelitis (skull base, temporal bone)
* fibrosis or stenosis of ear canal
* myringitis (inflammation of tympanic membrane)
* malignant otitis externa
29
management of acute otitis media
* *_If discharge present_* → oral + topical antibiotics
* **Amoxicillin 5/7** or erythromycin/clarithromycin
* *_No discharge_* + intact membranes → oral antibiotics
* Mastoid involvement
* Admission + IV Abx + Surgical drainage if mastoid abscess present
* antibiotic prescribing
* Immediate Abx → systemically unwell, high risk of complications, symptoms \> 4 days + no improvement
* Consider if \< 2 and bilateral, children with perforation/discharge
30
management of otitis media with effusion
**2WW ENT referral** - unilateral glue ear (esp. in adults) → Suggests posterior nasal passage obstruction e.g. CA
* **Conservative**
* Arrange hearing test
* Involve school if child to ensure accommodations made for ↓ hearing
* Smoking cessation/ensure not exposed to passive smoking
* Observe for 12 weeks to allow for self-resolution
* **Medical** - hearing aids long term permanent hearing loss
* **Surgical**
* *_Grommet insertion_* - equalisation of pressure within the middle ear and drainage of effusion
* Left in place for 1 year
31
what is rhinosinusitis
Refers to inflammation of nose and paranasal sinuses.
* Acute whereby condition resolves complete in 12 weeks
* Generally \< 4 weeks is acute, 4-12 is subacute, \> 12 weeks is chronic (see below)
* Recurrent acute sinusitis - 4+ episodes per year
32
management of acute sinusitis
1. Supportive measures
* Analgesia - OTC
* Nasal irrigation
* Warm face packs - can provide pain relief
2. **High dose nasal steroid**
* Indicated if **\> 10 days unwell**
* 14 day course
3. **Antibiotics (oral)**
* Indicated if \> 10 days duration, systemically unwell or high risk of complications due to co-morbidity
* 1st line - phenoxymethylpenicillin 500mg QDS for 5 days, doxycycline 200mg stat then 100mg OD 7/7 if penicillin allergic
* If systemically unwell → co-amoxiclav
33
management of chronic sinusitis
* **Medical treatment**
* **1st line - Steroid treatment**
* Long term topical initially
* Oral steroids for short term treatment may be required for some
* **Immunotherapy**
* Mepolizumab - anti-IL-5, MaB, very effective for severe polyposis
* Currently very expensive so not extensively used in clinical practise
* **Surgical intervention** (2nd line) - transforms people's QOL, removal of polyps
34
what is the centor score and intepretation?
* History of fever (\>38)
* tonsillar exudates
* no cough
* tender anterior cervical lymphadenopathy
* \> 3 = immediate Abx
35
what is the FeverPAIN score and interpretation
* Fever
* purulence
* attended within 3 days or less
* severely inflamed tonsils
* no cough/coryza
* \> 4 - immediate Abx
36
management of tonsillitis
* **Conservative**
* Watchful wait and reassurance if not high scoring - likely viral
* **Medical**
* Analgesia and anti-pyretic
* Antibiotics
* Indications: Centor score of 3/4, feverPAIN 4/5, marked systemic upset, immunodeficiency, hx of rheumatic fever
* **Penicillin V 500mg PO QDS for 5-10 days (phenoxymethylpenicillin)**
* Penicillin allergic - erythromycin/clarithromycin
* delayed antibiotic prescription if FeverPain score 2-3
* **Surgical**
* *Tonsillectomy*
37
what are the indications for tonsillectomy
* Indications- SIGN criteria for children and adults
* Sore throats are due to acute tonsillitis
* Disabling and preventing normal function during episodes
* One of the following:
* _\>_ 7 well documented, clinical significant, adequately treated sore throats in the preceding year
* _\>_ 5+ episodes in each of the preceding 2 years (10 total)
* _\>_ 3+ episodes in each of the preceding 3 years (9 total)
38
management of acute closed angle glaucoma
1. urgent ophthalmology
2. IV acetazolamide 500mg + topical beta-blocker (timilol) _+_ muscarinic antagonist topical (pilocarpine)
3. peripheral iridotomy/ laser trabeculoplasty
4. lens extraction if 3 ineffective
39
presentation of acute closed angle glaucome
* sudden onset
* **headache** - severe
* N&V
* **red + hard eye**
* **haloes**
* may be worst at night
* **cloudy cornea**
* **mid-dilated pupil**
40
presentation of chronic open angle glaucoma
* peripheral visual fields lost first
* cupping of optic disc on fundoscopy
41
RF for acute glaucoma
female, Asian, anti-muscarinic medication (e.g. amitriptyline), hypermetropia
42
RF for chronic glaucoma
myopia, FHx
43
management of chronic open angle glaucoma
1. refer to ophthalmology
2. medical
1. beta blocker or prostaglandin analogue or dual (topical)
2. topical alpha-2 agonist, carbonic anhydrase, topical miotic
3. laser trabeculoplasty
44
MOA of beta-blocker in glaucoma + example
* timolol
* reduces aqueous fluid production
45
MOA of prostaglandin analogue in glaucoma
* uveoscleral outflow
* e.g. latanoprost
46
SE of prostaglandin analogue topical in glaucoma
SEs: iris pigmentation, eyelash growth
47
MOA of topical alpha -2 agonist and example
* causes miosis opens blockage
* e.g. brimonidine tartrate, pilocarpine
48
MOA of carbonic anhydrase and example (glaucoma)
* ¯ aqueous production
* e.g. acetazolamide
49
what is the screening for glaucoma?
over 35, afro-caribbean, FHx, steroid treatment, DM, HTN, migraines, myopia
