ENT, Opthal, Plastics & OMFS Flashcards
Otitis Externa - define & causes
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)
Otitis Externa - presentation & examination features
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.
Otitis - diagnosis/investigations & management
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
Complications of Otitis Externa
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
Otitis Media - definition & causes
Acute inflammation of middle ear cleft & can have associated effusion
Bacterial - strep pneumoniae, haemophilus influenzae
Viral - RSV, rhinovirus, adenovirus
Otitis Media - Clinical Features
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
Otitis Media - Management
Conservative - analgesia & antipyretics
if pain >48hrs or systemically unwell can consider abx
Otitis Media - Complications
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
Cholesteatoma - define, S&S, management
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
Common Differentials for Dizziness/Vertigo & differentiating symptoms
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
Difference in Bell’s & Facial Palsy
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
Rhinosinusitis - types, presentation, management
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
Different Types of Hearing Loss & Causes
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
Tonsillitis - causes, S&S, scoring systems & management
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
Sore Throat Scores
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)
Complications of Tonsillitis
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
Red Flag Sx for Head & Neck Cancers
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
Patient presents to A&E with Epistaxis - management plan
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
Stridor - definition & causes
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
Management of a Child with Stridor
Call/seek senior help immediately Oxygen Nebulised adrenaline Steroids (Budesonide or Dexamethasone iv/oral) Heliox – 20% O2 80% H
Conjunctivitis - definition & types
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
Conjunctivitis - Clinical Presentation
Unilateral or bilateral red eye Bloodshot Itchy or gritty sensation Discharge (purulent = bacterial, watery = viral) Blurring of vision (due to discharge)
Red Eye Differentials
Painless - conjunctivitis, episcleritis, subconjunctival haemorrhage
Painful - glaucoma, anterior uveitis, scleritis, corneal abrasions, FB, traumatic or chemical injury
Conjunctivitis - Management
Bacterial - usually self limiting, chloramphenicol or fusidic acid
Viral - self limiting, reassurance & hygiene advised
Allergic Conjunctivitis - S&S, causes & management
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
Keratitis - definition & causes
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
Keratitis - Presentation
very painful red eye
no discharge
no longer tolerate contact lenses
Keratitis - Investigations & Management
Slit lamp & fluoresceine eye drops
Referral same-day if complex
Simple analgesia, lubricating eye drops, chloramphenicol eye drops & follow up
Anterior Uveitis (Iritis) - definition, causes, S&S & management
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
Episcleritis - definition, causes, S&S & management
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
Scleritis - definition, causes, S&S & management
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
Subconjunctival Haemorrhage - definition, causes, S&S & management
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
Cataracts - define, risk factors, S&S, management
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
Age related macular degeneration - define, RFs, S&S, management
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
Acute Closed Angle Glaucoma - define, RF, S&S, management
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
Acute Closed Angle Glaucoma - define, RF, S&S, management
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
Retinal Vein Occlusion - RFs, S&S, presentation, ivx & management
- 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
Central Retinal Artery Occlusions - RFs, S&S, management
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
Burns - describe classification
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
Fluid resuscitation formula for burns
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
Open Angle Glaucoma - define, aetiology, S&S, ix & mx
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
Diabetic Retinopathy - types, S&S, classification & mx
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
Retinal Detachment - define, S&S, mx
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
Amaurosis Fugax - describe & causes
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
Retinal artery occlusion - define, aetiology, S&S, mx
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
Optic Neuritis - define, aetiology, S&S, mx
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
Orbital vs Pre-orbital Cellulitis - differences & mx
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.
