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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

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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
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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
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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
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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

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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
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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
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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
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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
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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
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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
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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
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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
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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

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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
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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
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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
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18
Q

what is the NICE recommended diagnostics for infectious monomucleosis

A

NICE recommends in 2nd week of illness to confirm diagnosis monospot + FBC

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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
  • Imaging
    • Abdominal USS - assess for splenomegaly
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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
  • 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
  • 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
Q

most common causes of otitis externa

A
  • Staphylococcus aureus
  • Over time will be replaced by Klebsiella, E. Coli, Pseudomonas aeruginosa
    • Pseudomonas often seen in chronic or inadequately treated otitis externa
26
Q

what is malignant otitis externa?

A

Malignant otitis externa - “necrotising otitis”, potentially life-threatening, progressive external ear canal infection which may cause osteomyelitis of temporal bone + other skull bones

27
Q

management of acute otitis externa

A

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
Q

what are the complications of otitis externa

A
  • Chronic otitis externa
  • cellulitis
  • osteomyelitis (skull base, temporal bone)
  • fibrosis or stenosis of ear canal
  • myringitis (inflammation of tympanic membrane)
  • malignant otitis externa
29
Q

management of acute otitis media

A
  • 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
Q

management of otitis media with effusion

A

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
Q

what is rhinosinusitis

A

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
Q

management of acute sinusitis

A
  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
Q

management of chronic sinusitis

A
  • 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
Q

what is the centor score and intepretation?

A
  • History of fever (>38)
  • tonsillar exudates
  • no cough
  • tender anterior cervical lymphadenopathy
  • > 3 = immediate Abx
35
Q

what is the FeverPAIN score and interpretation

A
  • Fever
  • purulence
  • attended within 3 days or less
  • severely inflamed tonsils
  • no cough/coryza
  • > 4 - immediate Abx
36
Q

management of tonsillitis

A
  • 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
Q

what are the indications for tonsillectomy

A
  • 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
Q

management of acute closed angle glaucoma

A
  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
Q

presentation of acute closed angle glaucome

A
  • sudden onset
  • headache - severe
  • N&V
  • red + hard eye
  • haloes
  • may be worst at night
  • cloudy cornea
  • mid-dilated pupil
40
Q

presentation of chronic open angle glaucoma

A
  • peripheral visual fields lost first
  • cupping of optic disc on fundoscopy
41
Q

RF for acute glaucoma

A

female, Asian, anti-muscarinic medication (e.g. amitriptyline), hypermetropia

42
Q

RF for chronic glaucoma

A

myopia, FHx

43
Q

management of chronic open angle glaucoma

A
  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
Q

MOA of beta-blocker in glaucoma + example

A
  • timolol
  • reduces aqueous fluid production
45
Q

MOA of prostaglandin analogue in glaucoma

A
  • ­ uveoscleral outflow
  • e.g. latanoprost
46
Q

SE of prostaglandin analogue topical in glaucoma

A

SEs: iris pigmentation, eyelash growth

47
Q

MOA of topical alpha -2 agonist and example

A
  • causes miosis opens blockage
  • e.g. brimonidine tartrate, pilocarpine
48
Q

MOA of carbonic anhydrase and example (glaucoma)

A
  • ¯ aqueous production
  • e.g. acetazolamide
49
Q

what is the screening for glaucoma?

A

over 35, afro-caribbean, FHx, steroid treatment, DM, HTN, migraines, myopia

IK6 - Exams (24 decks)

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