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Finals > ENT, Opthal, Plastics & OMFS > Flashcards

ENT, Opthal, Plastics & OMFS Flashcards

1
Q

Otitis Externa - define & causes

A

Inflammation of outer ear (pinna & ear canal)

Swimmer’s ear, trauma, seborrhoeic dermatitis, contact dermatitis

Bacterial (staph aureus or pseudomonas aeruginosa)
Fungal (candida or aspergillus)

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2
Q

Otitis Externa - presentation & examination features

A

ear pain, discharge, hearing loss, itchiness

erythema & swelling in ear canal, tenderness, pus or discharge, lymphadenopathy

Tympanic membrane may be obstructed by wax or discharge, may be red if the otitis externa extends. If it is ruptured, the discharge in the ear canal might be from otitis media rather than otitis externa.

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3
Q

Otitis - diagnosis/investigations & management

A

clinical diagnosis - can take swab for organism

1st line - acetic acid spray (earCalm OTC)
2nd line - ciprofloxacin drops, otomize spray (neomycin, dexamethasone, acetic acid)

If skin involvement or extensive infection - flucloxacillin or clarithromycin

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4
Q

Complications of Otitis Externa

A

malignant or benign necrotising otitis externa

usually elderly or immunocompromised
Infection spreads from skin of ear canal to bone i.e. skull base osteomyelitis
Severe pain & granulation tissue on floor of ear canal
Same day admission under ENT needed

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5
Q

Otitis Media - definition & causes

A

Acute inflammation of middle ear cleft & can have associated effusion

Bacterial - strep pneumoniae, haemophilus influenzae
Viral - RSV, rhinovirus, adenovirus

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6
Q

Otitis Media - Clinical Features

A

Otalgia (ear pain)
Hearing loss
Fever
Tugging at ear (young children)

Red, yellow or cloudy tympanic membrane
Bulging or perforated TM
Air fluid level behind TM

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7
Q

Otitis Media - Management

A

Conservative - analgesia & antipyretics

if pain >48hrs or systemically unwell can consider abx

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8
Q

Otitis Media - Complications

A

Chronic Suppurative Otitis Media (CSOM): chronic inflammation of middle ear & mastoid cavity with recurrent ear discharge through TM perf
S&S: ear discharge (for more than 2 weeks) with or without pain or fever, hx of AOM or trauma, painless ear examination w/ TM perf
Management - referral to ENT, may need abx or steroid therapy or surgical approach

Otitis media with effusion - fluid in middle ear, painless deafness, a/w cleft plate & Down’s Syndrome, mx with insertion of Grommet’s or hearing aids

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9
Q

Cholesteatoma - define, S&S, management

A

Abnormal sac of keratinizing squamous epithelium and accumulation of keratin within the middle ear or mastoid air cell spaces which can become infected and also erode neighbouring structures

Recurrent or chronic purulent aural discharge (smelly & not responding to abx),

Referral to ENT - CT & audiology assessment, surgical approach

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10
Q

Common Differentials for Dizziness/Vertigo & differentiating symptoms

A

BPPV (benign paroxysmal positional vertigo) - lasts seconds to minutes, often turning over in bed, no asso sx

Meniere’s Disease - episodic, lasts hours, a/w tinnitus, aura, pressure in ear & deafness, gradual sensorieural deafness with more episodes

Vestibular Neurnitis - inflammation of vestibular nerve, often after URTI, lasts days/weeks, can be bed bound for a week before settling after 6 weeks due to central compensation, severe rotationally vertigo no asso sx

Labyrinthritis - inflammation of inner ear, lasts days/weeks, a/w tinnitus, deafness

Vestibular migraine - lasts hours, a/w migraine, photo/phonophobia, visual aura

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11
Q

Difference in Bell’s & Facial Palsy

A

Facial nerve palsy - Bell’s is idiopathic so if you know the cause it is facial palsy

common ent cause = adenoid cystic carcinoma of parotid gland
• If it infiltrates lower branches of facial nerve can cause also a forehead sparing picture but is still LMN

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12
Q

Rhinosinusitis - types, presentation, management

A

Acute <12/52, usually viral (<5/7), occasionally bacterial infection but completely resolves
Recurrent acute rhinosinusitis - acute but >3 episodes throughout the year
Chronic Rhinosinusitis; lasting longer than >12/52, +/- nasal polyps, never completely resolves, v strongly linked to respiratory problems (asthma, COPD)

p/w nasal congestion/obstruction, facial pain/pressure, nasal discharge, loss or reduction sense of smell

acute - usual viral so analgesia & reassurance
chronic - saline douching BD, intranasal corticosteroid spray, add abx if nasal polyps present, surgical options if maximal therapy doesn’t help

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13
Q

Different Types of Hearing Loss & Causes

A

Conductive (ear canal, ear drum, ossicles) - wax, otitis externa, otosclerosis, perforated ear drum, glue ear

Sensorineural (nerve, cochlea) - congenital, age related, noise damage, ototoxicity, Meniere’s, infections e.g. meningitis, AI

Cortical (brainstem or auditory cortex) - auditory processing disorder, brain tumour, brain surgery or stroke

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14
Q

Tonsillitis - causes, S&S, scoring systems & management

A

Viral (most commonly) or bacterial (group A strep or Streptococcus pneumoniae)

Sore throat, dysphagia, fever, feeling unwell, unable to eat or drink
Enlarged erythematous tonsils, lymphadenopathy, white exudate on tonsils (bacterial cause)

Centor or FeverPAIN scoring system

Management - analgesia/anti-pyretic (viral), +/- abx dependent on score

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15
Q

Sore Throat Scores

A 
Centor - 3 or more consider abx 
Tonsillar exudate
Tender anterior cervical lymphadenopathy or lymphadenitis
History of fever (over 38°C)
Absence of cough

FeverPAIN >2 consider abx
Fever (during previous 24 hours)
Purulence (pus on tonsils)
Attend rapidly (within 3 days after onset of symptoms)
Severely Inflamed tonsils
No cough or coryza (inflammation of mucus membranes in the nose)

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16
Q

Complications of Tonsillitis

A

Quinsy - peri tonsillar abscess, collection of pus
p/w severe tonsilitis + fever, unable to open mouth, hot potato voice, dysphagia

Investigations: observations (ensure not septic), full blood panel, imaging can be used if felt that spread beyond peri-tonsillar space

Management:
Medical - IV analgesia & fluids as unable no oral intake, IV abx & steroids
Surgical - may be surgical drainage or aspiration of pus

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17
Q

Red Flag Sx for Head & Neck Cancers

A 
Persistent/unexplained lumps - mouth, lip, tongue, neck, thyroid
Unexplained ulceration in mouth for >3 weeks
Erythroplakia or erythroleukoplakia 
Change in voice - hoarseness 
Unexplained weight loss  
Blood in saliva
Dysphagia / odynophagia
Otalgia
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18
Q

Patient presents to A&E with Epistaxis - management plan

A

1) Primary Survey (A-E)
○ More likely ABC - catastrophic haemorrhage
2) Basic First Aid
○ If haemodynamically stable sit patient forward/upright, apply pressure to little’s area for approx. 10mins, spitting out any clots etc
○ Take history & ?examine
3) If hasn’t stopped after 10mins - packing
○ Seek senior help (if haven’t packed a nose before) or ENT consult if ?facial injuries
○ Also at this point gain IV access - full baseline panel of bloods (FBC, U&Es, clotting profile, LFTs)
4) Despite packing still bleeding
○ Refer to ENT if haven’t done so already
○ Options: cautery - silver nitrate sticks or surgical repair/embolization for more posterior bleeds

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19
Q

Stridor - definition & causes

A

noisy or high-pitched sound with inspiration (or expiration or both) - a sign that the upper airway is partially blocked. It may involve the nose, mouth, sinuses, larynx, or trachea

Epiglotitis - leaning forwards, dribbling, caused by haemophilus influenza
Laryngomalacia - soft, flappy larynx, causes congenital stridor
Croup - parainfluenza, barking cough
Supraglottis (adults)
FB

20
Q

Management of a Child with Stridor

A 
Call/seek senior help immediately 
Oxygen
Nebulised adrenaline 
Steroids (Budesonide or Dexamethasone iv/oral) 
Heliox – 20% O2 80% H
21
Q

Conjunctivitis - definition & types

A

inflammation of conjunctiva

bacterial - staph aureus, staph epidermidis, strep pneumoniae, h. influenza

viral - adenovirus, herpes, coxsackie

allergic - exposure to pollen, cat, dogs, house dust mites

22
Q

Conjunctivitis - Clinical Presentation

A 
Unilateral or bilateral red eye 
Bloodshot 
Itchy or gritty sensation 
Discharge (purulent = bacterial, watery = viral)
Blurring of vision (due to discharge)
23
Q

Red Eye Differentials

A

Painless - conjunctivitis, episcleritis, subconjunctival haemorrhage

Painful - glaucoma, anterior uveitis, scleritis, corneal abrasions, FB, traumatic or chemical injury

24
Q

Conjunctivitis - Management

A

Bacterial - usually self limiting, chloramphenicol or fusidic acid

Viral - self limiting, reassurance & hygiene advised

25
Q

Allergic Conjunctivitis - S&S, causes & management

A

Allergic Conjunctivitis
• Rapid onset - itching, burning, grittiness, lid swelling, conjunctival oedema
• Causes: exposure to pollen, cat, dogs, house dust mites
• On examination conjunctival redness will be present with a watery discharge
• Management: systemic antihistamines, topical antihistamines

26
Q

Keratitis - definition & causes

A

Corneal inflammation - can infective or non-infective

Viral - HSV. herpes zoster or varicella

Bacterial - due to RFs & check in corneal barrier due to trauma, chronic dry ears, exposure e.g. CN7 palsy, immunosuppression

Protozoan infection - a/w contact lens

AI or trauma

27
Q

Keratitis - Presentation

A

very painful red eye
no discharge
no longer tolerate contact lenses

28
Q

Keratitis - Investigations & Management

A

Slit lamp & fluoresceine eye drops

Referral same-day if complex

Simple analgesia, lubricating eye drops, chloramphenicol eye drops & follow up

29
Q

Anterior Uveitis (Iritis) - definition, causes, S&S & management

A

inflammation of anterior urea - iris, ciliary body & choroid

usually AI (A/W HLA-B27) but can also be infective, traumatic, ischaemic or malignant

Unilateral symptoms - red, painful eye, watering, visual sx (haloes, photophobia, floaters), ciliary flash

Management - topical steroids & anti muscarinics

30
Q

Episcleritis - definition, causes, S&S & management

A

benign self limiting inflammation of episclera (outermost layer of sclera)

patch in eye - mild or no pain, no dx or visual sx

tends to be a/w inflammatory conditions

Self limiting no tx needed

31
Q

Scleritis - definition, causes, S&S & management

A

Inflammation of full thickness of sclera

not caused by infection, a/w systemic inflammation conditions (SLE, RA, IBD)

Severe red painful eye, pain on movement, tenderness on palpation, eye watering, visual sx (photophobia & reduced VA), abnormal pupil reactions to light

Urgent referral - treatment topical & systemic steroids & immunosuppressants

32
Q

Subconjunctival Haemorrhage - definition, causes, S&S & management

A

leakage of blood vessels between sclera & conjunctiva

traumatic (or strenuous activity) & spontaneous (high BP, clotting disorders, warfarin, DOACs)

appears as bright red patch - no pain & vision not affected

Resolves spontaneously usually within 2 weeks
Underlying conditions may need further investigation & management

33
Q

Cataracts - define, risk factors, S&S, management

A

Cloudy/opacification of lens

Congenital or acquired - maternal rubella, trauma, diabetes, alcohol, smoking, steroids, hypoCa, chronic uveitis, increasing age

generalised blurring/reduction in vision, haloes, glare, loss of red reflex

surgical mostly - lens broken up into pieces & removed, replaced w/ artificial lens, day case under local

34
Q

Age related macular degeneration - define, RFs, S&S, management

A

Central retina (macula) undergoes degenerative changes

age, smoking, white or chinese ethnic origin, family hx, cardiovascular disease

gradual worsening of central visual field loss, reduced visual acuity, crooked or wavy appearance of straight lines. on examination: drusen on fundoscopy & scotoma

lifestyle changes to slow progression (avoid smoking, control BP, vitamin)
anti-VEGF injections for wet ARMD

35
Q

Acute Closed Angle Glaucoma - define, RF, S&S, management

A

Progressive optic neuropathy in which raised intraocular pressure is typically a key factor. Closed angle refers to closing or narrowing of angle between iris & cornea, closure of this angle inhibits drainage of aqueous humour and rising IOP

increasing age, female sex, chinese & east asian origin, shallow anterior chamber, some medications

severely painful red eye, teary, hazy cornea, fixed & dilated pupil, blurred vision, haloes around lights, a/w headache nausea & vomiting

Pilocarpine drops; acts on muscarinic receptors & causes constriction of pupil
Acetazolamide 500mg - reduces aq humour production
Analgesia & Anti-emetic
Steroids

Secondary Care - extra steps apart from the above
Laser iridotomy

35
Q

Acute Closed Angle Glaucoma - define, RF, S&S, management

A

Progressive optic neuropathy in which raised intraocular pressure is typically a key factor. Closed angle refers to closing or narrowing of angle between iris & cornea, closure of this angle inhibits drainage of aqueous humour and rising IOP

increasing age, female sex, chinese & east asian origin, shallow anterior chamber, some medications

severely painful red eye, teary, hazy cornea, fixed & dilated pupil, blurred vision, haloes around lights, a/w headache nausea & vomiting

Pilocarpine drops; acts on muscarinic receptors & causes constriction of pupil
Acetazolamide 500mg - reduces aq humour production
Analgesia & Anti-emetic
Steroids
Secondary Care - Laser iridotomy

36
Q

Retinal Vein Occlusion - RFs, S&S, presentation, ivx & management

A
  • Hypertension
  • High cholesterol
  • Diabetes
  • Smoking
  • Glaucoma
  • Systemic inflammatory conditions e.g. SLE

Sudden painless vision loss, on examination: flame & blot haemorrhages, optic disc oedema, macula oedema

Screen for other associated conditions: history, FBC (leukaemia), ESR (inflammatory disorders), BP (hypertension), Serum glucose (diabetes)

Referred immediately to ophthalmologist
Management aims to treat macular oedema & prevent complications
Laser photocoagulation
Intravitreal steroids 
Anti-VEGF therapy
37
Q

Central Retinal Artery Occlusions - RFs, S&S, management

A

Most common cause - atherosclerosis, GCA, vasculitis
CV risk factors - obesity, diet, older age, family hx, smoking, alcohol, diabetes, hypertension

Sudden painless vision loss
Relative afferent pupil defect
Pale retina w/ cherry red spot

Refer to ophthalmologist immediately
No emergency management, more tx long term problems:
Macular oedema - anti VEGF
Neovascular glaucoma

If GCA - steroids

38
Q

Burns - describe classification

A

Superficial burn - epidermis only
• Red & painful, hypersensitive
• Heals w/o scar, no blisters
• Cap refill - blanches & refills quickly

Partial Thickness - superficial (epidermis + upper layer of dermis), deep (epidermis + deeper layers of dermis)
• Red or pale pink, blistering, very painful, blistering
• Scaring is variable
• Superficial - cap refill is slow // Deep - no cap refill, doesn’t blanch

Full Thickness - epidermis, dermis & underlying structures
• Can appear waxy white, leathery brown or charred black
• Typically non-painful, no blisters, no cap refill
• Heals with scar

39
Q

Fluid resuscitation formula for burns

A

o Fluid resuscitation (adults): 2 - 4 ml RL x Kg body weight x % burn
 First half of volume over first eight hours (from time of burn), second half over following 16 hours
CRYSTALLOIDS

In 2nd 24hrs - 0.5mL of 5% albumin x body weight (kg) x % burns

40
Q

Open Angle Glaucoma - define, aetiology, S&S, ix & mx

A

Definition: Glaucoma refers to increased IOP causing damage to optic nerve, open angle glaucoma is a gradual increased resistance to the blockage of aqueous humour drainage through the trabecular network

Aetiology & Risk factors:
Gradual increased resistance of flow through the trabecular network causing gradual increase in IOP. Risk factors inc:
	• Family history
	• Black ethnicity 
	• Myopia (nearsightedness)
	• Increasing age
Presentation/Clinical Features:
	• Asymptomatic in beginning - often picked up on screening/eye checks
	• Peripheral vision first affected - eventual tunnel vision
	• Gradual symptoms;
		○ Fluctuating pain in eye 
		○ Headaches
		○ Blurred vision
		○ Haloes around lights esp at night

Investigations & Diagnosis:
• Tonometry - non-contact & Goldmann’s
• Fundoscopy/slit lamp - looking for cupping of optic disc (>0.5x) & health of optic nerve
• Visual check - loss of peripheral vision

Management:
Medical
• Begin tx at IOP >24mmHg
• 1st line - latanoprost eye drops (prostagladin analogue)
○ Increases outflow
• Other options:
○ Beta blockers (timolol) - reduce production
○ Carbonic anhydrase inhibitors (dorzolamide) - reduce production
○ Sympathomimetics (brimonidine) - reduce production & increase outflow of aqueous humour

41
Q

Diabetic Retinopathy - types, S&S, classification & mx

A

Definition: Damage to the blood vessels within the retina due to prolonged exposure to high blood sugar levels, leading to progressive damage to retina
Types - non proliferative (mild, mod, severe) & proliferative DR

Aetiology & Risk factors:
Hyperglycaemia

Pathogenesis:
• Hyperglycaemia leads to damage to retinal blood vessels & endothelial cells - increased permeability - leakage - blot haemorrhages & hard exudates (yellow/white collections of lipids)
• Also leads to venous beading & microaneurysms
• Damage to nerve fibres - cotton wool spots
• Intraretinal microvascular abnormalities (IMRA) - dilated & tortuous capillaries in retina, act as shunt bet venous & arterial vessels in retina
• Neovascularisation occurs in proliferative DR

Non-Proliferative or Background DR
• Background - microaneurysms, dot & blot haemorrhages
• Mild - HMAs, cotton wool spots
• Moderate - >6CWS, small IMRA, dense HMAs in 1-3 quadrants
• Severe - dense HMAs in 4 quadrants, multiple or large IMRAs, venous beading in 2 quadrants

Proliferative DR
• Neovascularisation
• Vitreous haemorrhage

Presentation/Clinical Features:
	• gradually worsening vision.
	• sudden vision loss.
	• shapes floating in your field of vision (floaters)
	• blurred or patchy vision.
	• eye pain or redness.
	• difficulty seeing in the dark.

Investigations & Diagnosis:
• Fundoscopy

Complications of DR
	• Retinal detachment 
	• Vitreous haemorrhage 
	• Rebeosis iridis - new BV in iris
	• Optic neuropathy 
	• Cataracts

Management:
• Laser photocoagulation
• Anti-VEGF - ranibizumab
• Viteroretinal surgery - keyhole surgery in severe disease

42
Q

Retinal Detachment - define, S&S, mx

A

Definition: Retina becomes separated from choroid layer below - usually due to retinal tear which allows vitreous fluid in & separates layers, retina loses blood supply & vision loss occurs

Aetiology & Risk factors:
	• Older age 
	• Family history
	• Diabetic retinopathy
	• Trauma 
	• Retinal malignancy
	• Posterior vitreous detachment

Presentation/Clinical Features:
• Painless sudden loss of vision - peripheral loss, shadow coming across eye
• Blurred or distorted vision
• Floaters or flashes

Investigations & Diagnosis:
• Urgent referral to specialist

Management:
Management of retinal tears aims to create adhesions between the retina and the choroid to prevent detachment. This can be done using:
• Laser therapy
• Cryotherapy

Management of retinal detachment aims to reattach the retina and reduce any traction or pressure that may cause it to detach again. This needs to be followed by treating retinal tears as above. Reattaching the retina can be done using one of three options:
• Vitrectomy involves removing the relevant parts of the vitreous body and replacing it with oil or gas.
• Scleral buckling involves using a silicone “buckle” to put pressure on the outside of the eye (the sclera) so that the outer eye indents to bring the choroid inwards and into contact with the detached retina.
• Pneumatic retinopexy involves injecting a gas bubble into the vitreous body and positioning the patient so the gas bubble creates pressure that flattens the retina against the choroid and close the detachment

43
Q

Amaurosis Fugax - describe & causes

A

sudden, short-term, painless loss of vision in one eye.
The loss of vision occurs most commonly in adults over 50 and may last anywhere between a few minutes to a couple of hours

causes: embolic events (AS), optic neuritis (MS), GCA

44
Q

Retinal artery occlusion - define, aetiology, S&S, mx

A

Definition: Occlusion of retinal artery (branch of ophthalmic a. - branch of ICA)

Aetiology & Risk factors:
Causes:
• Atherosclerotic plaque/thrombosis
• Giant cell arteritis

Risk factors
• Atherosclerosis - smoking, age, diabetes, alcohol, obesity, diet etc
• GCA - GCA, PMR, >50yrs, females

Presentation/Clinical Features:
Sudden painless loss of vision
• Relative afferent pupillary defect (direct X, consensual - Y)
• Fundoscopy - pale retina w/ cherry red spot

Management:
• GCA is potentially reversible - ix & treat w/ high dose steroids
• The evidence supporting acute treatment of CRAO is limited. Treatment is usually attempted within 24 hours of presentation, but should be completed within 6 hours to improve efficacy.
○ Intra-arterial thrombolysis
○ Surgical intervention
○ Ocular massage etc
• Secondary prevention & management of RFs

45
Q

Optic Neuritis - define, aetiology, S&S, mx

A

Definition: Board term for inflammation, degeneration & demyelination of optic nerve

Aetiology & Risk factors:
• MS - up to 60% of cases
• Metabolic - severe B12 def, severe anaemia
• Infection - viral (HZV), bacterial (meningitis)
• Ischaemia - DM, atherosclerosis, GCA
• Other demyelination disorders

Presentation/Clinical Features:
• Unilateral loss of central vision; should recover in 2-6wks
• Dull ache pain of eye, worse on movement especially elevation
• Loss of colour vision
• O/E: central scotoma, loss of colour acuity, RAFD +/- papilloedema

Management:
• Dependent on cause
• TX w/ high dose steroids
• Referral to neurology after one isolated episode of optic neuritis

46
Q

Orbital vs Pre-orbital Cellulitis - differences & mx

A

Periorbital cellulitis (also known as preorbital cellulitis) is an eyelid and skin infection in front of the orbital septum (in front of the eye)

  • It presents with swelling, redness and hot skin around the eyelids and eye.
  • CT scan can help distinguish between the two.
  • Treatment is with systemic antibiotics (oral or IV).
  • Preorbital cellulitis can develop into orbital cellulitis so vulnerable patients (e.g. children) or severe cases may require admission for observation while they are treated.

ORBITAL CELLULTIS
• Orbital cellulitis is an infection around the eyeball that involves tissues behind the orbital septum.
• Key features that differential this from periorbital celluitis:
○ pain on eye movement, reduced eye movements, changes in vision, abnormal pupil reactions and forward movement of the eyeball (proptosis).
• This is a medical emergency that requires admission and IV antibiotics. They may require surgical drainage if an abscess forms.

Finals (16 decks)

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