ENT & Ophthalmology Flashcards
BPPV definition
disorder of recurrent episodes of vertigo accounting half pts with peripheral vertigo associated with head movements
BPPV cause
most idiopathic but associated with head trauma, labyrinthitis, otological surgery and vestibular neuronitis
otoconia debris comes loose into semi-circular canals
debris causes endolymph movement in canals with head movement
BPPV signs and symptoms
recurrent vertigo episodes <1min
provoked by head movements
peripheral vertigo (neg HINTS)
no symptoms of hearing loss, tinnitus or neuro deficits
positive Dix-Hallpike test - latent and fatigable nystagmus
BPPV mx
particle repositioning manoeuvres (Epley/Semont manoeuvre)
home exercises (Brandt-Daroff)
referral to balance specialist if sx unresolving and resistant to manouvres
Meniere’s disease pathophysiology
excess fluid production or impaired absorption of endolymph of inner ear
causes endolymph hypertension which causes symptoms
Meniere’s disease presentation
onset 20-40 yrs maybe FHx
rotatory episodic vertigo (mins to hrs)
sensorineural hearing loss, progressive and episodic
tinitus
associated with ear fullness
Meniere’s disease IX
audiology
otoscopy
MRI head if asymmetrical tinnitus/hearing loss to exclude acoustic neuroma
positive Romberg’s
positive Fukuda stepping test
peripheral HINTS exam
difficulty in heel-to-toe walking
sensorineural Rinne and Weber
Meniere’s mx
decrease salt, caffeine, alcohol, nicotine
avoid triggers
acute attack
- benzos +/- antiemetic
refractory symptoms
- try betahistine first as less SEs
- replace betahistine for thiazide diuretic (hydrochlorothiazide)
causes of conductive hearing loss
defects limiting sound conduction from auricle to ossicles
wax impaction
foreign bodies
otitis externa
tumour
otitis media
glue ear
cholesteatoma
ruptured TM
causes of unilateral sensorineural hearing loss
MS, brainstem stroke, Meniere’s acoustic neuroma
needs MRI scan and ENT referral
causes of bilateral sensorineural hearing loss
age-related (presbycusis)
noise exposure
ototoxicity (aminoglycosides, tetracyclines, chemotherapy)
how do you clinically differentiate sensorineural and conductive hearing loss
Conductive:
Rinne BC>AC
Weber localises to affected ear
Sensorineural loss:
Rinne AC>BC
Webber localises to unaffected ear
hearing investigations
pure tone air and bone conduction testing
speech audiometry
impedance audiometry
clear, watery nasal discharge with coryza and maybe fever. consider …
… common cold
clear, watery nasal discharge with Hx of head injury/surgery. consider …
… CSF rhinorrhoea!!!
clear, watery nasal discharge with history of allergy/atopy maybe itchy eyes maybe itchy nose. consider …
… allergic rhinitis
clear watery nasal discharge with headache and unilateral neurology. consider …
… migraine or cluster headache
clear watery nasal discharge in elderly patient excluding serious pathology. consider …
… senile rhinorrhoea
mucopurulent non-bloody nasal discharge with obstruction maybe anosmia maybe facial pain. less than a week. consider …
… acute rhinosinusitis (viral)
mucopurulent non-bloody nasal discharge with obstruction maybe anosmia maybe facial pain. more than a week, less than 12 weeks. maybe fever. consider …
… acute rhinosinusitis (bacterial)
mucopurulent non-bloody nasal discharge with obstruction maybe anosmia maybe facial pain. more than 12 weeks. consider …
… chronic rhinosinusitis
mucopurulent bloody discharge with unilateral nasal obstruction. consider…
… sinus/nasopharyngeal neoplasm
… nasal foreign body in a child or psychiatric adult
mucopurulent bloody discharge with septal perforation maybe crusting maybe nasal collapse. consider …
granulomatosis with polyangiitis (Wegner’s)
most common causes of acute viral rhinosinusitits
rhinovirus, influenza, parainfluenza
common causes of acute bacterial rhinosinusitis
strep.pneumoniae
h.influenzae
moraxella catarrhalis
acute rhinosinusitis mx
analgesia/antipyretics (paracetamol, ibuprofen)
nasal saline irrigation
oral nasal decongestant phenylephrine 1 wk
topical intranasal glucocorticoids
ABs if high suspicion bacterial (Penicillin V or doxycycline or clarithromycin)
if systemically unwell or high risk complications give co-amoxiclav
some chronic rhinosinusitis signs
inflammation
nasal polyps anteriorly
post nasal drip
anosmia
red flags:
visual changes
focal neurology
blood-stained
unilateral symptoms
chronic rhinosinusitis management
lifestyle: avoid triggers, stop smoking, dental hygiene, steaming
nasal saline irrigation
intranasal glucocorticoids up to 3mo
specialist referral
when would you refer chronic rhinosinusitis patient to specialist
if:
red flag symptoms
symptoms despite 3mo intranasal steroids
polyps complicating treatment
significant impact on QoL
rhinosinusitis complications
orbital:
- orbital/preseptal cellulitis
- orbital abscess
intracranial:
- meningitis
- cavernous sinus thrombosis
eye red flags
diplopia
eye pain on movement
decreased visual acuity
loss of colour vision discrimination
chemosis (oedema of sclera)
orbital, preseptal cellulitis ix
assess with ABCDE, look for sepsis, intracranial infection and assess for eye compromise
nasendoscopy to inspect mucosa and neurological examination with cranial nerves
if red flags:
admit. urgent CT sinus and brain, broad spectrum antibiotics and keep NBM
which vessels affected in anterior epistaxis
Kisselbach’s plexus (Little’s area)
which vessels affected in posterior epistaxis
Sphenopalatine artery
epistaxis ix
ABCDE approach
examine with thudicum speculum
endoscopy
epistaxis mx
1) assess with ABCDE approach maybe manage any hypovolaemia (IV access and crystalloids)
2) lean forward, pinch anterior nares, hold 20mins
3) examine with thudicum and cauterise anterior bleeds with silver nitrate
4) anterior packing with nasal tampon or gauze in paraffin, refer to ENT for admission
5) bilateral anterior packing maybe posterior packing (Foley catheter)
6) unresolving bleeds need arterial ligation in theatre (eg SPA ligation)
allergic conjunctivitis signs and symptoms
watery discharge + itchy + nasal sx + bilateral disease
viral conjunctivitis causes and symptoms
adenovirus, HSV
watery discharge + sticky eyes + bilateral disease +/- herpetic vesicular rash
bacterial conjunctivitis causes and symptoms
pneumococcus, stph.aureus, moraxella catarrhalis
purulent discharge + sticky eyes + unilateral + pannus
conjunctivitis ix
slit lamp
conjunctivitis mx
dont touch things between eyes, dont itch, dont share household items
wash hands and face and eyes regularly
if suspect bacteria, topical BS abx to reduce symptom duration if given before day 6
if suspect viral or allergic give topical antihistamines
if unresolving allergic try topical steroids or topical sodium cromoglycate
scleritis pathophysiology
painful destructive and vision threatening disorder of the sclera
half of pts associated with systemic illness
most cases are anterior scleritis
posterior and necrotising anterior are most serious. posterior often delayed recognition and close to optic nerve
scleritis signs and symptoms
severe pain constantly
exacerbated on eye movement
may have photophobia
look out for diplopia and reduced vision (compression of 2nd nerve)
in posterior less likely to have redness than anterior
scleritis ix
use slit lamp and look for:
scleral oedema and dilation deep episcleral vascular plexus (anterior)
choroidal thickening and retinal detachment (posterior)
may want B-scan ultrasonography to confirm scleral thickening
may also want CT/MRI to exclude orbital lesions
mild-moderate scleritis mx
anterior subtype
NSAIDs
if no response to NSAIDs or moderate anterior then try high dose prednisolone (+ eventually tapering)
severe scleritis mx
aggressive mx with high dose prednisolone and rituximab (anti-CD20)
if still not responding to rituximab try cyclophosphamide short as possible <3-6mo (high toxicity)
if responsive to cyclophosphamide eventually switch to less toxic medication:
azathioprine
methotrexate
mycophenolate mofetil
iritis signs
limbal redness (junction cornea and sclera)
irregular pupil
blurred vision
photophobia
throbbing and dull pain
cells and flare in anterior chamber on split lamp examination
iritis (anterior uveitis) causes
occurs with systemic conditions
seronegative spondyloarthropathies
rheumatoid arthritis
IBD
Bechet’s
Sarcoidosis
TB
Herpes
HIV
uveitis mx
if infectious use appropriate antimicrobial plus below
topical corticosteroid for anterior
peri/intra-ocular injections
cycloplegic (atropine, cyclopentolate) to paralyse ciliary body
if no response initial treatment, systemic glucocorticoids +/- immunosuppressants (MTX, azathioprine, mycophenolate)
transient acute visual loss. <24hrs. consider …
TIA
giant cell arteritis
papilloedema
seizure
migraine
posterior uveitis is inflammation of
choroid
retina
aetiologies posterior uveitis
herpes simples/ herpes zoster
toxoplasmosis
TB
CMV
lymphoma
sarcoidosis
Bechet’s
posterior uveitis signs and symptoms
ACTIVE INFLAMMATION OF CHOROID OR RETINA + LEUCOCYTES IN VITREOUS HUMOUR
painless and no redness
eye floaters
reduced visual acuity
unilateral ptosis with miosis?
Horner’s syndrome
unilateral ptosis with opthalmoplegia
CN III palsy
ptosis with fatiguability
myasthaenia gravis
bilateral ptosis with midbrain signs
supranuclear CN III palsy
bilateral ptosis with chronic progressive opthalmoplegia
Myopathies
what does monocular diplopia suggest
monocular diplopia is present when only one eye is open
suggests orbital pathology
what does binocular diplopia suggest
present when both eyes are open, absent when one is closed
suggests neurological, NMJ or muscular pathology
