ENT & OPHTHALMOLOGY Flashcards
What are some causes for conductive hearing loss?
- External canal obstruction = wax, pus, foreign body
- TM perforation = trauma, barotrauma, infection
- Ossicle defects = otosclerosis, infection, trauma
- Inadequate eustachian tube ventilation of the middle ear = effusion 2ndary to nasopahryngeal carcinoma
What are some causes of sensorineural hearing loss?
- Drugs - streptomycin, gentamycin, hydroxychloroquine
- Post-infective = meningitis, measles, mumps, flu, herpes, syphillis
- Meniere’s disease
- Cochlear valvular disease
- Acoustic neuroma
- Trauma
- Presbycusis
Describe briefly, what is the difference in terms of sound conduction between conductive, sensorineural + mixed hearing loss.
- Sensorineural both air + bone conduction are reduced
- In conductive, only AC impaired
- in mixed, both AC + BC are affected, often with AC being worse
What is otosclerosis? Who does it tend to affect?
New bone formation around the stapes, which leads to fixation + consequent conductive hearing loss
- autosomal dominant
- typically manifests between 20-40yrs
What are the clinical features you would expect in a patient with otosclerosis?
- bilateral conductive deafness
- hearing IMPROVES when background noise present
- worsened by pregnancy/menopause/menstruation
- tinnitus
- mild transient vertigo
- positive FHx
How do you manage a patient with otosclerosis?
- Hearing aid - including BAHA
- Surgery - stapes implant
- Cochlear implant
What are the typical clinical features that a patient with presbyacusis will present with?
Tend to be over 65yrs
- B/L hearing loss
- Speech is difficult to understand, they struggle to use telephone + having to turn up volume of TV
- hearing is WORSE in noisy environments
- loss of directionality of sound
- slow onset and may have associated tinnitus
What investigations would you perform in a patient with presbyacusis?
- OTOSCOPY - R/O otosclerosis, cholesteatoma, conductive hearing loss
- TYMAPNOMETRY - normal middle ear function
- AUDIOMETRY - B/L sensorineural pattern
How is prebyacusis managed?
Hearing aid
What are the clinical features of otitis externa?
- watery discharge
- itch
- pain + tragal tenderness
- on otoscopy = red, swollen, eczematous ear canal
When would you consider doing an ear swab in a patient with otitis externa?
- Treatment fails
- OE chronic or recurrent
- Topical treatment cannot be delivered (e.g. EAC occluded)
- Infection has spread beyond EAC
- Infection is severe enough to require oral Abx
How do you manage a patient with otitis externa?
- Manage aggravating/precipitating factors
- Consider cleaning EAC if wax/debris blocks topical med application
- Consider topical abx with or without steroid
- e.g. ciprofloxacin with dexamethasone
- use for at least 7 days. If symptoms persist can use for up to 14 days - Consider earwick insertion if extensive swelling of EAC
- Oral abx rarely indicated
- clarithromycin or flucloxacillin
What self-care advice should you give pts with otitis externa?
- Avoid damage to EAC - do NOT use cotton ear buds
- Keep the ears clean + dry
- Ensure pre-disposing conditions are controlled e.g. eczema, dermatitis
What patients are at risk of developing malignant/necrotizing otitis externa? Why is it life-threatening
Immunocompromised => 90% of pats are diabetics
- Life-threatening as can cause temporal bone osteomyelitis
What investigation should be performed in suspected necrotizing OE?
CT
How is malignant/necrotizing OE managed?
Non-resolving OE with worsening pain = urgent ENT referral
- Surgical debridement
- IB Abx
- Specific immunoglobulins
What are some risk factors for developing otitis media?
- bottle fed
- passive smoking
- dummy use
- asthma
- cleft-palate
- GORD
- raised BMI
How does acute otitis media present? Including what would be seen on ototscopy
- Usually occurs in children post-URTI
- Rapid onset ear pain, with child tugging at ear
- Irritable, fever, vomiting
- purulent discharge if drum perforates
O/E:
- bulging red TM
- loss of normal landmarks
- may have a fluid level
How is acute otitis media managed?
- Advise that the usual duration is about 3 days but can be up to 1-week
- Optimize analgesia e.g. regular ibuprofen + paracetamol
- Antibiotics - amoxicillin or clarithromycin
- only use if systemically unwell
When would you consider admitting someone with acute otitis media?
- Severe systemic infection
- Suspected acute complications = meningitis, mastoiditis, intracranial abscess, sinus thrombosis, facial nerve palsy
- children under 3-months with a fever or over 38 degrees
What are risk factors for developing OME (glue ear)?
- Downs syndrome
- Cleft palate
- Cystic fibrosis
- Primary ciliary dyskinesia
Allergic rhinitis
If otitis media with effusion occurs in an adult, what must be ruled out?
Post-nasal space tumour
What are the clinical features you would expect in a pt with OME (glue ear)?
HEARING LOSS
- inattention at school
- poor speech development
- hearing impairment
O/E:
- retracted dull TM
- fluid level present
- normal TM does NOT rule out OME
Why do we worry about persistent, foul smelling discharge?
?Cholesteatoma
- urgent ENT referral required
What investigations should be performed in patients with OME?
- Tympanometry = flat tympanogram in OME
2. Audiometry = conductive hearing deficit
How do you manage patients with OME?
- Active observation for 6-12 weeks
- spontaneous resolution is common
- include 2 hearing tests
- consider ENT referral - Autoinflation
- balloon in young kids
- valsalva in older children - Myringotomy
- insertion of grommets. They last about 10 months. Be aware of risk of infection
What is the criteria for ENT referral in patients with OME? (HINT there are 6)
- Hearing loss associated with impact on childs development/education
- Hearing loss is severe = 2ww to r/o sensorineural deafness
- Significant hearing loss on 2 or more occasions
- Tympanic membrane structurally abnormal
- Persistent smelly discharge
- Child has downs or cleft palate
What are the features of chronic suppurative otitis media?
- PAINLESS discharge + hearing loss for over 2 weeks
- Hx of AOM, ear trauma or glue ear + grommet insertion
- Hx of allergy + URTI
- Tinnitus/sensation of pressure in ear
O/E = TM perforation
What are the important red flag symptoms in a patient with CSOM which may suggest serious complications?
Mastoiditis or intracranial infection:
- Headache
- Vertigo
- Labyrinthitis
- Paralysis
- Nystagmus
- Fever
- Swelling/tender behind ear
How is CSOM diagnosed?
Must refer to ENT as they are to make diagnosis
How is CSOM managed?
- Topical/systemic Abx
- Surgery (myringoplasty)
- persistent discharge
- mastoiditis
- cholesteatoma
What is a cholesteatoma?
Locally destructive expansion of stratified squamous epithelium within the middle ear
What are the typical clinical features of a cholesteatoma?
PERSISTENT FOUL SMELLING DISCHARGE
- Headache, pain
- Conductive hearing loss
- CN involvement (= disease progression) e.g. vertigo, sensorineural hearing loss, meningitis, facial paralysis
When would you urgently refer or semi-urgently refer patients with suspected cholesteatoma?
URGENT:
- with suspected cholesteatoma AND a serious complication including; facial nerve palsy or vertigo, other neurological signs (incl. pain) or signs that could be associated with the development of an intracranial abscess or meningitis
SEMI-URGENT:
- suspected cholesteatoma with NO serious complications
How is a suspected cholesteatoma investigated?
- Audiology assessment
2. CT head - for complications
How do you manage pts with cholesteatoma?
- Mastoidectomy
2. Steroid + Abx if infection
What are the clinical features of mastoiditis?
- fever (pt is usually very unwell)
- Protruding auricle
- Tender, swollen + red mastoid
- May have a hx of recurrent OM
What investigation should be done in suspected mastoiditis?
CT head
How do you manage pts with mastoiditis?
- IV Abx
2. Myringotomy with or without mastoidectomy
How do you manage Ramsay-Hunt syndrome?
Give oral aciclovir + prednisolone within first 72h
What are the 3 red flag symptoms in a patient presenting with nasal blockage?
- Unilateral
- Persistent despite 3 months treatment
- Epistaxis
What are some predipsosing factors to developing rhinosinusitis?
- Atopy
- Nasal obstruction - septal deviation or polyps
- Recent local infection - rhinitis, dental extraction
- Swimming/diving
- Smoking
What are the clinical features of acute sinusitis?
- Facial pain
- typically frontal pressure worse on bending forwards - Discharge
- from nose. Thick + purulent - Nasal obstruction/congestion
- Anosmia
How do you manage patients with acute sinusitis?
- Analgesia
- Intranasal decongestants or nasal saline
- Intranasal steroids if symptoms present for more than 10-days
- Phenoxymethylpenicillin if symptoms are severe
What are the clinical features of chronic rhinosinusitis WITH polyps?
- Watery anterior rhinorrhoea
- bilateral nasal obstruction
- purulent post-nasal drip
- cheek pain
- mouth breathing
- snoring
What investigations should you perform in patients with suspected chronic rhinosinusitis WITH polyps?
- Nasal endoscopy
- Anterior rhinoscopy
- RAST
- CT sinuses
- Biopsy
How do you manage patients with chronic rhinosinusitis WITH polyps?
- Topical nasal steroid - betamethasone 0.1%
- Short course of prednisolone
- Nasal saline irrigation
- Antibiotics if evidence of infection
- Antihistamine + allergen avoidance
- Endoscopic sinus surgery
- advise NOT to blow nose + continue steroids
- SEs = CSF leak, optic nerve damage
What are the clinical features of chronic rhinosinusitis WITHOUT polpys?
- B/L intermittent nasal blockage
- sneezing
- rhinorrhoea
What investigations should be performed in chronic rhinosinusitis WITHOUT polyps?
- Thuddicums speculum
- Nasal endoscopy
- RAST
How do you manage chronic rhinosinusitis WITHOUT polyps?
- Antihistamine if clear evidence of allergy e.g. loratidine
- Topical nasal steroid e.g. betamethasone 0.1%
- Saline nasal irrigation
- Sinus surgery if unresponsive to medical treatment
What are the classifications of allergic rhinitis?
- Seasonal
- symptoms around same time every year - Perennial
- symptoms throughout the year - Occupational
- Symptoms follow exposure to particular allergens within workplace
What are the clinical features of allergic rhinitis?
- Sneezing
- B/L nasal obstruction
- Clear nasal discharge
- Post-nasal drip
- Nasal pruritus
How do you manage allergic rhinitis?
- Allergen avoidance
- Oral/intranasal anti-histamines
- Intranasal corticosteroids
What is the centor criteria + how is it used to manage cases of tonsillitis?
- Cough absent (+1)
- Exudate on tonsils (+1)
- Tender/swollen cervical nodes (+1)
- Temperature over 38 (+1)
- also if 3-14 yrs (+1) or 45 and above (-1)
Consider Abx if score 3/4.
- Penicillin V or erythromycin
What are some indications for a tonsillectomy?
- For recurrent tonsillitis if ALL of:
- caused by tonsillitis
- 5+ episodes a year
- Episodes disabling + prevent normal functioning
- symptoms for more than 1y - Airway obstruction e.g. OSA in children
- Quinsy
- Suspicion of cancer e.g. unilateral enlargement or ulceration
List some complications which can arise as a result of a sore throat?
- Peritonsillar abscess (Quinsy)
- Retropharyngeal abscess - rare
- Scarlet fever
- Rheumatic fever
- Post-streptococcal glomerulonephritis
- malaise + ‘smoky’ urine 1–2 wks after pharyngitis
How do you manage a patient with a quinsy?
ADMIT
- IV Abx
- incision + drainage under LA or tonsillectomy under GA
What is Scarlet fever? How is it treated?
‘Sandpaper’ like rash on chest, axillae or behind ears 12-48h after pharyngotonsillitis
- circumoral pallor
- strawberry tongue
Treatment = start Penicillin V/G + notify public health
What are the clinical features of rheumatic fever?
- carditis
- arthritis
- subcutaneous nodules
- erythema marginatum
- sydenham’s chorea
What is laryngomalacia?
Immature + floppy aryepiglottic folds + glottis causing laryngeal collapse on inspiration
How does laryngomalacia tend to present?
STRIDOR in children
- presents within the first few weeks of life
- noticeable at certain times e.g. lying on back, feeding, excited/upset
Problems can occur with concurrent laryngeal infections or with feeding
How is laryngomalacia managed?
Usually no treatment is required BUT severe cases may warrant surgery
How do you manage epiglottitis?
Do NOT examine the throat or cause any distress
- Contact anaesthetists + ENT
- O2 + nebulised adrenaline
- IV Dexamethasone
- Cefotaxime
- Take to theatre to secure airway by intubation
What is a pharyngeal pouch? What are the typical symptoms?
More common in OLDER men
- usually not seen but if large then a midline lump in the neck which gurgles on palpation
Symptoms = dysphagia, regurgitation, aspiration + a chronic cough
What is a branchial cyst?
Oval, mobile cystic mass that develops between sternocleidomastoid muscle + pharynx
- develop due to failure of obliteration of 2nd branchial cleft in embryonic development
- usually present in early adulthood
What are the clinical features of infectious mononucleosis?
Triad of:
- Fever
- Pharyngitis
- Lymphadenopathy - may be present in anterior or posterior triangles of neck (tonsilitis only involves upper anterior chain)
Others:
- lymphocytosis, malaise, anorexia, headache, hepatitis, palatal petechiae, splenomegaly (rupture can occur)
What investigations can be performed in suspected infectious mononucleosis?
- FBC - lymphocytosis
2. Monospot test in 2nd week of illness
How do you manage infectious mononucleosis?
- Rest in early stages, drink plenty of fluids, avoid alcohol
- Simple analgesia
- Avoid contact sports for 8 weeks
What occurs in acute angle closure glaucoma?
When iris bulges forward + seals off trabeuclar meshwork from the anterior chamber preventing aqueous humour being able to drain
- causes a continual increase in pressure in eye
What are some risk factors for AACG?
- increasing age
- females 4x more likely
- FHx
- Chinese + East Asian origin
- Shallow anterior chamber
What medications can precipitate AACG?
- adrenergics e.g. noradrenaline
- anticholinergics e.g. solifenacin
- TCAs e.g. amitriptyline
- Angle narrowing e.g. cyclopentolate
What are the symptoms + signs of AACG?
HEADACHE + PAINFUL RED EYE
- blurred vision, haloes around lights, N+V, onset over hrs to days
O/E:
- red eye, teary
- hazy cornea, decreased visual acuity, dilatation of affected pupil, fixed pupil
- decreased VA
If you see someone in GP with suspected AACG, what do you do?
SAME-DAY OPHTHALMOLOGY ASSESSMENT REQ
- will have tonometry (raised IOP over 40mmHg)
- Gonioscopy
- slit lamp
How do you manage AACG?
Avoid dark rooms as dilatation worsens angle closure
- Pilocarpine - constricts
- Azetazolomide - decreases aqueous humour
- Timolol
- Analgesic + anti-emetic
What is the definitive management of AACG?
Peripheral laser iridectomy in BOTH eyes
What are some risk factors for retinal detachment?
- previous hx
- cataract surgery
- trauma
- myopia
- DM
- ARMD
What are the clinical features of retinal detachement?
PAINLESS - peripheral vision loss (like a shadow) - blurred/distorted cision 4 F's: - Floaters - Flashes - Field loss - Fall in VA
How do you manage retinal detachment?
URGENT OPHTHALMOLOGY R/V
- Rest
- Laser photocoagulation - fix tear in retina
- Surgery to fix detachment
- vitrectomy or gas tamponade
What is the most common cause of central retinal artery occlusion?
Atherosclerosis
- also can be caused by GCA
What are the clinical features of central retinal artery occlusion?
DRAMATIC SUDDEN PAINLESS LOSS OF VISION
- acuity is finger counting or worse
- RAPD may precede retinal changes
What will fundoscopy show in central retinal artery occlusion?
Pale retina with a cherry red spot
How do you manage central retinal artery occlusion?
Attempt to restore ocular blood flow within 100 mins
- Ocular massage
- Surgical removal of aqueous humour
- Intraocular antihypertensives
- Inhaled carbogen to dilate the artery
What does retinal vein occlusion look like on fundoscopy?
- Flame + blot haemorrhages
- Optic disc oedema
- Macular oedema
How do you manage retinal vein occlusion?
IMMEDIATE OPHTHALMOLOGY R/V
- Aim is to treat macular oedema + prevent complications. Options:
1. Laser photocoagulation
2. Intravitreal steroids
3. Anti-VEGF
How do you differentiate between periorbital (preseptal) + orbital cellulitis?
periorbital is less serious + will not have any eye pain or visual problems
What investigations + management should be performed in suspected orbital cellulitis?
- FBC - raised WCC + CRP/ESR
- Conjunctival swab
- Orbital CT
- Blood cultures
Management = Urgent CT + ophthalmology review + IV Abx
What are some (i) painless (ii) painful causes of red eye?
(i) conjunctivitis, episleritis, subconjunctival haemorrhage
(ii) Painful:
- glaucoma
- anterior uveitis
- scleritis
- corneal abrasions/ulceration
- keratitis
- foreign body
- traumatic/chemical injury
What are some indications for immediate Abx for conjunctivitis?
- STI
- contact lens wearer
- immunocompromised
How do you manage conjunctivitis?
Most cases resolve within 5-days without treatment:
- Artificial tears - hydromellose
- Chloramphenicol or Fusidic acid if bacterial
- Antihistamine if allergic
What patient advice should you give to people with conjunctivitis?
- irrigation to remove purulent discharge may be helpful
- contact lens wear avoided until 48h post infection resolution
- wash hands + don’t share towels
- seek medical attention if condition deteriorates
What conditions is episcleritis associated with?
Inflammatory disorders e.g. RA and IBD
How do you differentiate between scleritis + episcleritis?
EPISCLERITIS
= painless/mild pain, no visual loss
SCLERITIS
= painful, gradual vision loss
How is epislceritis managed?
Conservatively
- usually resolves in 1-4wks
- lubricating eye drops
- analgesia + cold compress
- safety net
How is a subconjunctival haemorrhage managed?
Harmless + will resolve spontaneously within 2-weeks
- think about investigating possible causes e.g. HTN + bleeding disorders
What conditions are associated with anterior uveitis?
HLA-B27
- ankylosing spondylitis
- IBD
- reactive arthritis
CHRONIC
- sarcoidosis
- syphillis
- Lyme disease
- TB
- herpes virus
What are the clinical features of anterior uveitis?
Unilateral features which start spontaneously.
- acute pain + photophobia
- blurred vision, decreased VA
- floaters + flashes
- miosis, lacrimation
- pain on movement
- pupil dilates irregularly + hypopyon
How is anterior uveitis managed?
URGENT referral + control of underlying disease
- Prednisolone 1% drops
- Cyclopentolate 1% 8-hrly to maintain pupil dilatation to prevent adhesions
What are the clinical features of keratitis?
- pain, photophobia
- vesicles around eye
- watering eye
- decreased VA
- foreign body sensation (enquire about mouth + genital ulcers)
What condition will show dendritic corneal ulcers?
Keratitis
When should you perform an MRI in pts presenting with CN6 palsy?
- other CN palsies also present
- younger than 35
- B/L papilloedema
How do you manage CN6 palsies?
Most microvascular palsies resolve within 3-6 months
- Temporary prisms in glasses
- Botox injection into medial rectus can limit the squint
If a patient with a third nerve palsy presents with fixed pupil dilation, what should you be worried about?
Suggests compression from SOL
- urgent neuroimaging required
- suspect posterior communicating/internal carotid artery aneurysm
What will patients with a 4th nerve palsy not be able to do?
Look down + in
What are some causes of a gradual loss of vision?
- cataract
- glaucoma
- diabetic retinopathy
- hypertensive retinopathy
- ARMD
- retinitis pigmentosa
- vit A deficiency
What are the clinical features of ARMD?
Gradual loss of CENTRAL vision
- reduced VA
- crooked/wavy appearance of straight lines
- difficulty reading + making out faces
- worsening vision at night + with changing light conditions
What is seen on examination in ARMD?
- Reduced VA on snellen
- scotoma (= central patch vision loss)
- amsler grid shows straight line distortion
- fundoscopy has DRUSEN in dry
How do you manage DRY ARMD?
No specific treatment - lifestyle measures may slow progression
- avoid smoking
- controlling BP
- vitamin supplementation
How do you manage WET ARMD?
- Anti-VEGF medications (ranibizumab)
- Laser photocoagulation
- Photodynamic therapy
- Intravitreal steroids
What are the risk factors for primary open-angle glaucoma?
- aged over 50
- IOP over 23mmHg
- FHx glaucoma
- myopia (short-sightedness)
- black ethnicity
What are the clinical features of primary open-angle glaucoma?
Asymptomatic rise in IOP
- peripheral vision loss
- tunnel vision
How do you manage primary open-angle glaucoma?
- Topical prostaglandin analogues = lantoprost, travoprost
- Topical beta-blockers = betaxolol (caution asthma + HF)
- Topical alpha agonists = brimonidine
- Carbonic anhydrase inhibitors (acetazolomide)
- Pilocarpine
- Laser trabeculoplasty
- Trabeculoectomy/stents
What are the clinical features of cataracts?
Usually asymmetrical as each eye is affected separately:
- very slow reduction in vision
- progressive blurring of vision
- colour goes brown/yellow
- starbursts around lights
- LOSS OF RED REFLEX
What does cataract surgery involve?
Drilling + breaking lens into pieces, removing pieces + then implanting an artificial lens into the eye
- usually done as a day case under LA
What is mild NPDR classed as?
1 or more microaneurysm
What is moderate NPDR classed as?
- microaneurysms
- blot haemorrhages
- hard exudates
- cotton wool spots, venous beading/looping + intraretinal microvascular abnormalities (IRMA)
What is severe NPDR classed as?
- blot haemorrhages + microaneurysms in 4 quadrants
- venous bleeding in at least 2 quadrants
- IRMA in at least 1 quadrant
What is proliferative diabetic retinopathy classed as?
- retinal neovascularisation, may lead to vitreous haemorrhage
- fibrous tissue forming anterior to retinal disc
- more common in T1DM
What is maculopathy? Who is it more common in?
- based on location rather than severity - any are potentially serious
- any hard exudates or other changes on macula
- more common in T2DM
How do you manage non-severe NPDR?
Observation - strive to achieve optimum glycaemic + hypertensive control
How do you manage severe NPDR?
Consider pan-retinal photocoagulation
How do you manage proliferative diabetic retinopathy?
Urgent pan-retinal photocoagulation
How is hypertensive retinopathy staged?
Keith-Wagener Classification
