ENT & Opthalmology Flashcards
Name 5 symptoms which should be asked about for any hearing changes history?
Same in both ears? Tinnitus? Discharge? Pain? Vertigo/ spinning etc.?
Name 3 non symptom factors which should be asked in a hearing loss history?
Trauma/ water exposure
Occupation (noise exposure)
PMHx and DHx (causative drugs)
How do you distinguish between conductive and sensorineural hearing loss (one Hx question and then examination findings?)
Q: If you are in a crowd of people is it easier to tell what someone is saying to you (conductive) or more difficult (sensorineural)
Webers (lateralises to either conductive deaf on same side or sensorineural on the opposite)
Rinne’s- positive is normal, negative means conductive deafness on that side
If you have a R sided conductive deafness, which side would Webers test lateralise to?
Right side
Conductive deafness is ipsilateral
Name 4 differentials for a bilateral hearing loss?
Wax
Noise induced
Presbycusis (sensorineural hearing loss caused by old age)
Vascular/ chemo/ syphiliis
Name 5 differentials for a conductive hearing loss?
Wax Foreign body Otitis externa/ media Otosclerosis Tympanic membrane perforation Cholesteatoma
Give 4 differentials for a sensorineural hearing loss?
Labrinthitis (acute onset vertigo, nausea and vomitting)
Noise induced
Presbycusis (gradual, slow onset)
Meniere’s disease (recurrent vertigo, mins to hours with ringing or buzzing)
What is the most common cause of, and how do you manage a perforated ear drum?
Cause: Infection (also barotrauma or trauma)
Tx: Usually heals by itself in 6-8 weeks
- Prescribe AB’s if due to infection
- If this fails can do myringoplasty
How do you treat otitis media in a child over 6 months age?
Paracetamol/ ibuprofen for fever (alternate but not together) Antibiotics only if: - Syxlasting over 4 days - Perforation - Discharge - Bilateral + age <2
Name three groups of children who should be admitted with a suspected ear infection?
- Age < 3months
- 3-6 months with temp >39
- Systemically unwell
- Acute complications (mastoiditis/ meningitis)
What antibiotics should be given to children with acute otitis media (for example lasting >4days and needing AB’s)
Amoxicillin (5 day course)
- Macrolide if allergic
How do you diagnose and treat BBPV?
Dix-hallpike to diagnose?
Epley manoeuvre to treat
What is the classic presentation of BPPV?
Age approx 55, uncommon in younger
Vertigo triggered by change in head position, nausea
Episodes last 10-20 seconds
James, 40, has presented to his GP with weakness of the right side of his face, which examination confirms. James also reveals that he has experienced pain in his ear and otoscopy reveals the presence of vesicles on his tympanic membrane. Which of the following is the likely diagnosis?
Ramsay Hunt Syndrome
(Reactivation of Varicella Zoster)
- Pain in ear
- Vesicles on tympanic membrane
- Facial paralysis
- Hearing loss, tinnitus, vertigo, taste loss etc.
How is otitis media treated in adults?
Same as kids (paracetamol)
AB’s only if >4days, discharge or perforation or systemically unwell etc)
What are the main symptoms of otitis externa?
Ear pain
Itching
Possible discharge
Possible hearing loss
When are swabs recommended in otitis externa?
If there has been treatment failure or if atypical situation
How is otitis externa treated if the ear is red, odematous or showing discharge?
Topical antibiotics (neomycin or clioquinol)
+
Topical steroid
(Betamethasone, hydrocortisone)
Treat for at least one week (but continue for a maximum of two weeks if needed)
How long should otitis externa take to settle down?
Approximately one week
What should be used for mild cases of otitis externa (no redness, discharge, hearing loss etc)?
If just pain and itching consider using topical acetic acid
When are oral antibiotics indicated for acute otitis externa?
Fever
Regional lymphaenopathy
Cellulitis spreading beyond the ear
A px presents with vertigo, what is the best way to distinguish between BPPV, labyrinthitis and meniere’s?
BPPV: Episodes <30seconds, triggered by specific postures
Labyrinthitis: Episode can last for days, can be triggered by ANY movement, preceding viral infection common. Can experience hearing loss.
Meniere’s: Episodes last mins-hours. Associated more with aurual fullness, tinnitus and hearing loss
How should labyrinthitis be treated?
Prochlorperazine (for acute phase (days) only)
- General advice is to lie down with eyes closed during acute attack but when begins to reside to get active as soon as possible, this may reduce attack severity
If symptoms of bacterial ear infection (discharge etc.) then also give AB’s
How long does labyrinthitis take to settle down?
Several days to three weeks
How do you treat acute and chronic meniere’s disease?
Acute: Prochlorperazine
Chronic: Betahistine can be used as prophylaxis
Px should notify DVLA with any vertigo
Lifestyle: Low salt, cut out alcohol, chocolate, caffeine and tobacco
What features of a sore throat would raise concern about epiglottitis? (5)
Inability to swallow secretions or fluids Muffled 'hot potato' voice Very high fever Dyspnoea Stridor (surgical emergency)
How do you manage suspected epiglottitis?
Admit immediately
Usually IV AB’s but may also need intubation or in severe cases trachyostomy
What is the best management of epistaxis? (assuming it has only just started) - 5 points
Sit upright, lean forward for 10-20 mins
If no success consider:
- Cautery
- Packing
- Topical tranexamic acid
- Artery ligation if complete emergency
What are some preventative treatments for epistaxis?
Nasal cautery (silver nitrate)
Can consider Naseptin (chlorhexidine and neomycin) topically also
What is a cholesteatoma and how does it present?
Collectional of epidermal/ connective tissues in middle ear, can be locally invasive and destructive (such as by affecting bones of middle ear)
Presentation: Progressive conductive hearing loss, otorrhoea
- Possible vertigo, facial nerve palsy or headache
How is a cholesteatoma treated?
Surgical removal
Medical only to be used if px unsuitable for GA or refusing surgical Tx (topical and systemic AB’s) and regualr cleaning
What is otosclerosis?
Single most common cause of hearing impediment Genetic cause (autosomal dominant) with variable penetrance so 1/4 risk if one parent affected, 1/2 if both.
When and how does otosclerosis usually present and how common is it?
Age 15-35 (bilateral progressive conductive hearing loss and tinnitus)
Affects 1 in 40 people but symptoms only 1 in 300
How does otosclerosis present?
Bilateral (70%) progressive conductive hearing loss
Low tones are hardest to hear (deep male voices)
What investigations should be performed for suspected otosclerosis?
Audiometry (shows purely conductive, predominantly low tone loss)
How is otosclerosis treated?
Surgical day case (stapedectomy or stapedotomy) - 95% success in resolving hearing loss
Or use hearing aids
What is otitis media with effusion (glue ear)?
Fluid in middle ear with chronic inflammation but no signs of acute inflammation
How does otitis media with effusion (OME) usually present?
Most common cause of hearing loss in children
Hearing loss is main symptom but mild pain, popping of ears, recurrent ear infections may be possible
How should you manage OME (glue ear) in children? (3)
Observe for 3 months (50% spont recovery in 3/12, 90% in 12/12)
No proven benefit from any medication or alternative therapy
Refer to surgery if bilateral >3months, hearing loss in best ear >25dB or impact on development
- This is for grommets
How does a thyroglossal cyst usually present? (3)
How are they treated?
More common <20 years
Midline
Moves up with protrusion of the tongue (Remember tongue is thyroGLOSSAL and tongue done by GLOSSOpharngeal nerve)
Tx: Surgical removal
How do swellings of the thyroid gland usually present?
May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing (A thyroid swelling moves up on swallowing)
How does a cystic hygroma usually present? (2)
Congenital (presents < age 2)
Classically on left hand side
How does a branchial cyst usually present?
Oval, mobile cystic mass between sternocleidomastoid and pharynx
Usually presents in early adulthood
How does a peritonsillar abscess usually present and how is it treated?
Following bacterial tonsilitis:
- Severe throat pain, lateralising to one side
- Deviation of the uvula to the unaffected side
- Trismus (difficulty opening the mouth)
- Reduced neck mobility
Tx is urgent ENT review and often needle aspiration
Name 3 differentials for a child with stridor?
Croup (age 6 months - 3 years), also barking cough, fever, coryzal syx
Acute epiglottitis (v.unwell, rapid onset, drooling)
Inhaled foreign body (sudden onset coughing, choking, vomiting)
Name 3 features of sinusitis?
Facial pain (typically front pressure, worse bending forward) Nasal discharge Nasal obstruction (mouth breathing) Post-nasal drip
How should sinusitis be managed?
Analgesia
Intranasal decongestants
(Can take up to 2-3 weeks to resolve)
What are the NICE recommendations for tonsillectomy indication?
At least 5 episodes of tonsilitis per year
Going on for at least one year
Episodes are disabling and prevent normal functioning
How is tonsillitis distinguished from infectious mononucleosis (glandular fever)
Prolonged malaise and fatigue more likely
Possible macular non-itchy rash
How should infectious mononucleosis be treated? (4)
Avoid alcohol and contact sports for min 1 month
Paracetamol for fever and analgesia + keep well hydrated
If prescribing AB’s for tonsilitis, which AB is first line?
10days of phenoxymethylpenicillin
Or clarithromycin if allergic
What is the CENTOR criteria?
Cough (absent = 1) Exudates (yes=1) Nodes (yes=1) Temp (>38=1) OR (if <14 = +1, if over 45 = -1)
Consider AB’s in those with a score of 3/4
A 44-year-old man comes to see you as he noticed pain in his left ear which started 3 days ago while he was cleaning his ears out with cotton buds. He reports that his left ear has been hurting since and he thinks his hearing is also affected. On examination, you note a perforated left eardrum.
What is the most appropriate management?
Watch and wait
- Should resolve itself in 6 weeks
If no resolution in 6 weeks then consider ENT referral
What is the definition of acute suppurative OM?
Otitis media with PUS in the middle ear
A 32-year-old woman presents with a long history of chronic ear infections. She complains of an offensive discharge from her right ear with associated hearing loss for months. She has had severe vertigo for the last 48 hours.
What is the most likely diagnosis?
Cholesteatoma
What is a +ve (normal) result for Rinne’s test?
Air louder than bone
Air conduction > bone conduction
If the other way round then there is conductive deafness
What antibiotic should be used for diabetics which otitis externa?
Ciprofloxacin to cover for pseudomonas
Red eye in a contact lens wearer should be presumed to be what until proven otherwise?
Keratitis (to be seen same day)
Name 5 history features of acute angle closure glaucoma?
Old and hypermetropic (long-sighted) patient Pain Blurred vision Halo's around point lights Photophobia Systemically unwell (N+V, headache)
Name 3 examination findings of acute angle closure glaucoma?
Red, injected eye
Fixed, mid dilated pupil
Hazy cornea (odema due to glaucoma)
Reduced VA
Name 2 examination findings on opthalmoscopy in diabetic retinopathy?
(Bilateral findings)
Microaneurysms
Dot and blot haemorrhages
Cotton wool spots
How does diabetic retinopathy present, how should diabetics be monitored?
Aysymptomatic or slow visual loss
TIght glycemic control, do annual screening for diabetics
How does hypertensive retinopathy show on examination with an opthalmoscope?
(Bilateral findings - similar to diabetic)
- Microanurysms
Cotton wool splots
Retinal haemorrhages
A patient is found to have a swollen optic disc on examination, what should your next step be, name 3 differentials?
CT/ MRI head (then LP once SoL has been excluded)
- Space occupying lesion
- Intercranial hypertension
- Subdural/ subarchnoid haemorrhage
- Optic neuritis
How does primary open angle glaucoma tend to present?
Central vision preserved
Loss of visual fields
(Although often asymptomatic for a significant amount of time)
Which form of glaucoma is most common? What is the other type?
Open angle - more chronic and most common
Closed angle- Leads to pain, halo’s headaches, N+V etc.
What is a cateract and how does a px present?
An opacity in the eye, leading to reduced VA and possible glaring of lights and reduced colour sensitivity
What are the most common causes of cateracts (3)?
Age Diabetes Calcium disorders Uveitis Angle-closure glaucoma Wilsons disease
How is chronic open angle glaucoma treated? Name 3 examples of drops?
Latanoprost (prostaglandin analogue - increase drainage)
Timolol (beta blocker, reduce pressure)
Pilocarpine (Miotic, makes the pupil smaller)
How does a central retinal vein occlusion present?
Syx: Sudden unilateral visual loss, transient reduction in vision followed by complete recovery
How does a retinal detachment present?
Flashing lights and floaters
Curtains or shaddows across part of visual field
Decreased vision
Black dots in vision
What is the difference between dry and wet AMD?
Dry (90%) - Non exudative and just build up of drusen (lipids and proteins)
Wet (10%) - Exudative - development of new blood vessels which leak fluid and lead to scarring - most common cause of blindness in western world
How does AMD present?
Classically central visual loss
Straight lines can look wavy
Older patients, RF’s include FHx, female, smoking, HTN, hypercholesterolaemia
A 71-year-old with a history of type 2 diabetes mellitus and hypertension presents due to the sensation of light flashes in his right eye. These symptoms have been present for the past 2 days and seem to occur more at the peripheral part of vision. There is no redness or pain in the affected eye. Corrected visual acuity is measured as 6/9 in both eyes. What is the most likely diagnosis?
Flashes and floaters are symptoms of PVD (posterior vitreous detachment), patient is at risk of retinal detachment so needs urgent referral
James, 40, has presented to his GP with weakness of the right side of his face, which examination confirms. James also reveals that he has experienced pain in his ear and otoscopy reveals the presence of vesicles on his tympanic membrane. What is the likely diagnosis?
Ramsay Hunt syndrome, type 2, is a condition where reactivation of pre-existing Varicella Zoster virus occurs. This is the reason for the vesicles on the tympanic membrane. Ramsay Hunt syndrome can also cause pain in the ear, facial paralysis, taste loss, dry eyes, tinnitus, vertigo and hearing loss
Cherry red spot is associated with what?
Central retinal artery exclusion
A px presents with painful red eye, give 5 differentials?
AACG - Halo’s, photophobia, N+V
Uveitis - Pain on accommodation, photophobia, no systemic
Scleritis - gradual onset, can go into forehead/ jaw,
Keratitis - Foreign body sensation, more likely if Hx contact lenses
Trauma
A patient presents with a non-painful red eye, give 3 differentials?
Conjunctivitis - Gritty and itchy feeling
Episcleritis - No pain or discharge, just redness
Subconjunctival haemorrhage - Asymptomatic, should resolve in 2/52 but refer if raised BP or trauma
What are the three causes of conjuctivits and when would you suspect each?
Allergic (itchy)
Viral (watery discharge and raised LN’s)
Bacterial (unilateral, sticky discharge)
How should conjunctivitis be treated?
Likely self resolve in 1-2 weeks
If concern bacterial = topical chloramphenicol (fucidic acid if pregnant)
Name 5 differentials for sudden painless visual loss?
Central retinal artery occlusion Retinal vein occlusion Retinal detachment - Flashes of light and floaters Vitreous haemorrhage Ishcemic optic neuropathy
Name 4 differentials and salient points for a slow onset visual loss?
1) AMD
- Worsening central vision, straight lines become curvy
2) Cataracts
- Blurred or cloudy vision, glare at night, decreased colours
3) Glaucoma
- Peripheral visual loss
4) Diabetic retinopathy
Name 5 things which should be asked about in the HPC for visual symptoms?
Uni/bilateral Timing of onset Pain Blurring Photophobia Discharge Systemic (headache, N+V) Trauma Recent contact with infected individuals
A 3-year-old boy is brought to the clinic by his mother who has noticed a mass in his neck. On examination; he has a smooth mass located on the lateral aspect of his anterior triangle, near to the angle of the mandible. On ultrasound; it has a fluid filled, anechoic, appearance.
Branchial cysts are usually located laterally and derived from the second branchial cleft. Unless infection has occurred they will usually have an anechoic appearance on ultrasound.
A 22 month old baby is brought to the clinic by her mother who is concerned that she has developed a swelling in her neck. On examination; she has a soft lesion located in the posterior triangle that transilluminates.
Cystic hygromas are soft and transilluminate. Most are located in the posterior triangle.
A 2-year-old boy is brought to the clinic by his mother who has noticed that he has developed a small mass. On examination; a small smooth cyst is identified which is located above the hyoid bone. On ultrasound the lesion appears to be a heterogenous and multiloculated mass. MLD?
Dermoid cysts are usually multiloculated and heterogeneous. Most are located above the hyoid, and their appearances on imaging differentiate them from thyroglossal cysts.
Dendritic ulcers seen following flurorescein eye stain suggests what pathology?
Herpes simplex keratitis
You see a 3-year-old boy as a follow-up appointment. Two weeks ago he presented with left-sided otalgia associated with a purulent discharge. You prescribed amoxicillin and arranged to see him today. His mum reports that he is much better and says she has managed to keep the ear dry. On examination of the left side a perforation of the tympanic membrane is noted. What is the most appropriate action?
Advise to keep ear dry and see in further 4 weeks time
What is the most common bacterial cause of otitis media?
Haemophilus influenzae
What are the criteria for tonsillectomy consideration?
> 5 episodes/ yr
Episodes are disabling and prevent normal function
A 7-year-old girl presents to the emergency department with bleeding from her throat. She is 8 days post-tonsillectomy for recurrent tonsillitis. She had been recovering well from the surgery until today. O/E there is a small amount of active bleeding from the tonsillar fossae. She is haemodynamically stable, though she complains of pain and her temperature is 38.2ºC.
What is the most appropriate management?
Admit for IV AB’s
Haemorrhage 5-10 days after tonsillectomy is commonly associated with a wound infection and should therefore be treated with antibiotics
A 25-year-old man presents with an acute history of sudden intense vertigo on waking, with loss of balance affecting his right side and pain in the right ear. There is no associated deafness or tinnitus. On examination he has a nystagmus with the rapid component to the right. MLD?
Vestibular neuronitis
- Sudden and near-complete loss of vestibular function in a young patient is suggestive of vestibular neuronitis, a condition assumed due to a self-limiting viral infection of the vestibular nerve. Can do vestibular rehab but should self-resolve within 5 days.
How should nasal polyps be managed?
Unilateral - Urgent ENT referral (red flag for cancer)
Bilateral - Routine ENT referral
- Tx of topical steroids improves in 80%
How does postnasal drip present?
Post-nasal drip (PND) occurs as a result of excessive mucus production by the nasal mucosa. This excess mucus accumulates in the throat or in the back of the nose resulting in a chronic cough and bad breath.
