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YEAR 4 - ACC > Headache + ENT > Flashcards

Headache + ENT Flashcards

1
Q

What is meningococcal disease?

A

Meningococcal septicaemia
OR
Meningococcal meningitis

Or a combination of both

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2
Q

What are the main causes of bacterial meningitis?

A

Neonates

  • Group B strep
  • Listeria monocytogenes
  • E. coli

Infants

  • H. influenzae
  • N. meningitides
  • S. pneumoniae

Adults
- same as infants

Elderly

  • S. pneumoniae
  • L. monocytogenes
  • TB
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3
Q

What are some non-infective causes of meningitis?

A 
Malignant cells
Drugs - NSAIDs, trimethoprim
Sarcoidosis
SLE
Behcet's disease
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4
Q

What are some early features of meningitis?

A 
Headache
Fever
Leg pains
Cold hands and feet
Abnormal skin colour
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5
Q

What features make up ‘meningism’?

A
  • Neck stiffness
  • Photophobia
  • Kernig’s sign = pain and resistance on passive knee extension with hip fully flexed
  • Bruzinkski’s sign = involuntary lifting of leg when lying supine and head is raised
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6
Q

How would meningitis present in an infant?

A

High-pitched cry
Bulging fontanelle
Vomiting
Drowsiness

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7
Q

What indicates invasive meningococcal disease?

A
  • Petechial rash that is non-blanching (use glass test to check)
  • Signs of shock: prolonged cap refill, hypotension, tachycardia
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8
Q

What investigation should you do first in suspected meningitis?

A

Blood cultures

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9
Q

After taking blood cultures, how is meningitis managed?

A
  • IV antibiotics - start immediately on any clinical suspicion
  • IV dexamethasone 10mg - to reduce meningism
  • Airway support
  • Fluid resuscitation
  • LP (only do this before IV antibiotics if they are stable; CI in raised ICP and coagulopathies)
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10
Q

What is the blind/empirical therapy for meningitis?

A

IV ceftriaxone (3rd generation cephalosporin)

If atypical pathogens, add IV amoxicillin
If Listeria, add gentamicin

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11
Q

What antibiotic should GPs give to treat meningitis in the community?

A

IM benzylpenicillin

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12
Q

What should be given as prophylaxis to those in close-contact with meningitis?

A

Rifampicin

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13
Q

What complications can arise from meningitis?

A

Immediate complications:

  • DIC
  • Raised ICP
  • Pericardial effusion

Delayed complications:

  • Encephalopathy
  • Hearing loss
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14
Q

Describe the CSF analysis in bacterial, viral + TB meningitis

A

Bacterial

  • Cloudy, turbid appearance
  • > 1.5g/L protein (normal 0.2-0.4)
  • Low glucose
  • Neutrophils ++++

Viral

  • Clear appearance
  • Normal protein
  • Normal glucose
  • Lymphocytes ++++

TB

  • Cob-web like appearance
  • > 1.5g/L protein
  • Low glucose
  • Lymphocytes ++++
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15
Q

What is the most common focal neuropathy with a space occupying lesion?

A

CN VI palsy - most common as it has long intracranial path

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16
Q

What causes temporal arteritis?

A

Autoimmune vasculitis affecting the posterior ciliary arteries

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17
Q

Who should you always consider temporal arteritis in?

A

All patients over 50 years with a recent sudden onset headache

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18
Q

What condition is temporal arteritis associated with?

A

Polymyalgia rheumatica

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19
Q

How does temporal arteritis present?

A 
Headache
Scalp tenderness e.g. when combing hair
Tongue/jaw claudication - pain on chewing
Amaurosis fugax - transient visual loss 
Sudden unilateral blindness
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20
Q

What is the risk with temporal arteritis?

A

Irreversible bilateral visual loss - can occur suddenly if not treated so emergency refer to ophthalmologist

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21
Q

What are some extracranial symptoms of temporal arteritis?

A 
Malaise
Dyspnoea
Weight loss
Morning stiffness
Unequal or weak pulses
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22
Q

How does the retina appear in temporal arteritis?

A

Pale papilloedema
Pale, waxy, elevated disc = ischaemia
Splinter haemorrhages

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23
Q

What bloods must be done in temporal arteritis?

A

ESR - raised >47

CRP - raised

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24
Q

What provides a definitive diagnosis of temporal arteritis?

A

Temporal artery biopsy - within a week of starting steroids

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25
Q

What is the treatment for temporal arteritis?

A

Start prednisolone 60mg OD immediately to avoid visual loss

If there is visual loss/history of amaurosis fugax - IV methyprednisolone

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26
Q

What presents similarly to subarachnoid haemorrhage?

A

Venous Sinus Thrombosis

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27
Q

What is venous sinus thrombosis?

A

Acute thrombosis (blood clot) in the dural venous sinuses (which normally drain blood from the brain) causing cerebral infarction

28
Q

Which sinus is most commonly affected by venous sinus thrombosis?

A
  1. Sagittal sinus thrombosis

2. Transverse sinus thrombosis

29
Q

What are the risk factors for venous sinus thrombosis?

A

Prothrombotic haematological conditions (thrombophilia)

Hormonal factors (pregnancy, COCP, peri-partum period)

Local factors (sinus infection, trauma, skull abnormalities)

Systemic disease (malignancy, dehydration, sepsis)

30
Q

What is the onset of symptoms like in venous sinus thrombosis?

A

Gradually come on over days or weeks

31
Q

How does venous sinus thrombosis present depending on the sinus affected?

A

Sagittal sinus (most common) - headache, vomiting, seizures, decreased vision, papilloedema

Transverse sinus - headache, mastoid pain, focal CNS signs, seizures, papilloedema

Sigmoid sinus - cerebellar signs, lower cranial nerve palsies

Inferior petrosal sinus - CN V & VI palsies, temporal and retro-orbital pain

Cavernous sinus - headache, chemosis, swollen eyelids, proptosis, painful ophthalmoplegia, fever

32
Q

What often causes cavernous sinus thrombosis?

A

Spread from facial pustules or folliculitis

33
Q

What imaging is done for venous sinus thrombosis?What would you see on the imaging?

A

Non-contrast CT - hyperdensity in the affected sinus (i.e. absent sinus)

CT venogram - might be initially normal but show filling defect at 1 week (delta sign)

MRI T2-weighted images - visualise thrombus directly

34
Q

How do you treat venous sinus thrombosis?

A

LMWH to anticoagulate
Then start warfarin to reach INR 2-3
If unresolved, give thrombolysis or mechanical thrombectomy

35
Q

When is a mechanical thrombectomy futile?

A

Large infarcts

Impending herniation

36
Q

Name some triggers of migraines

A

CHOCOLATE

Chocolate
Hangovers
Orgasms
Cheese/caffeine
Oral contraceptives
Lie-ins
Alcohol
Travel
Exercise
37
Q

What precedes the headache in a migraine?

A

Prodromal symptoms

  • Hours/days
  • Yawning
  • Cravings
  • Sleep or mood changes
38
Q

What types of aura may occur during a migraine?

A

Aura

  • Visual
  • Somatosensory - paraesthesiae
  • Motor - dysarthria, ataxia, hemiparesis
  • Speech - dysphasia
39
Q

Describe the headache in a migraine. What associated symptoms present with the headache?

A

Headache

  • Unilateral, pulsating headache
  • Can wake patient in the night

Associated symptoms

  • Nausea + vomiting (only once or twice)
  • Photophobia, phonophobia
40
Q

What is the prophylactic treatment of migraines?

A
  • Propanolol
  • Amitryptiline
  • 12 weekly botulinum toxin injections in chronic migraines
41
Q

How do you treat a migraine during an attack?

A
  1. Simple analgesic with anti-emetic e.g. paramax = combination preparation
    of ibuprofen + prochlorperazine
  2. Triptans = 5-HT1 (serotonin) receptor agonist
42
Q

What usually causes otitis media?

A

Viral URTI - adenoid pads enlarge and block off eustachian tube

43
Q

Who commonly presents with otitis media?

A

Children aged 3-6 years, following URTI

44
Q

How does otitis media present?

A

Earache and deafness
Fever

Discharge is a later sign associated with a decrease in pain due to perforated tympanic membrane

45
Q

What test identifies the side of the hearing loss?

A

Weber’s test

  • Conductive hearing loss = loudest in affected ear
  • Sensorineural hearing loss = quieter in affected ear
46
Q

How can you distinguish between whether it is a conductive or sensorineural hearing loss?

A

Rinne’s test - if the tuning fork is perceived louder on the mastoid process, there is a conductive hearing loss

47
Q

When should you treat otitis media with antibiotics?

A

Perforation
Bilateral otitis media
Infants below age of 2

48
Q

What is the first line antibiotic for otitis media?

A

Amoxicillin

49
Q

What is a complication of otitis media?

A

Mastoiditis - boggy swelling behind the ear, pushes the ear forward

50
Q

What most commonly causes bacterial tonsillitis?

A

Group A beta-haemolytic streptococcus

51
Q

What else can cause purulent exudate in the throat?

A

Epstein Barr Virus

52
Q

What criteria is used to predict whether tonsillitis has a bacterial cause?

A

Centor criteria

  • Tonsillar exudate
  • Anterior cervical lymphadenopathy
  • Temperature > 38
  • Absence of cough

If >2 consider treating with antibiotics

53
Q

What investigation can be done if EBV is suspected?

A

Monospot test

54
Q

What antibiotics are used to treat bacterial tonsillitis?

A

1st line - PO phenoxymethylpenicillin 500mg QDS for 10 days (unless allergic)
2nd line - clarithromycin

55
Q

What should you never prescribe for tonsillitis?

A

Amoxicillin

If it were EBV, it would cause all over body rash

56
Q

What is a complication of tonsillitis?

A

Quinsy = peritonsillar abscess

57
Q

What is the cardinal feature of encephalitis?

A

Altered mental status - this is less prominent in meningitis

58
Q

What is the most common cause of encephalitis?

A

Herpes simplex virus type 1

59
Q

Aside from altered mental status, how might encephalitis present?

A

Flu-like prodromal symptoms
Fever
New seizures

60
Q

What is the gold standard investigation for suspected encephalitis?

A

LP with CSF sent for viral PCR

61
Q

What is the best imaging modality for suspected encephalitis?

A

MRI (because CT head often appears normal acutely)

62
Q

What is the typical distribution of herpes simplex encephalitis?

A

Temporal distribution

63
Q

What is the management of suspected encephalitits?

A

Treatment should be initiated while awaiting definitive diagnosis of the condition as the progression of HSE is very rapid

  1. Immediate IV acyclovir 10mg/kg TDS for 2 weeks
  2. Broad spectrum antimicrobial cover with 2g IV ceftriaxone BD
  3. Supportive management of complications e.g. anticonvulsants for seizures
64
Q

What is a side effect of acyclovir that must be monitored for? How do you minimise the risk of the side effect

A

Nephrotoxicity - acyclovir can crystallise in the glomeruli

Manage with adequate hydration and dose tapering

65
Q

What is the criteria for head CT after head injury (as recommended by NICE)?

A

Clinical evidence of skull fracture

More than 30 minutes retrograde amnesia.

Focal neurological deficit or seizure.

GCS <13 at any time (or <15 2 hours after injury).

More than 1 episodes of vomiting.

Loss of consciousness and any amnesia in patients who:

  • Are >65 years
  • Suffered a dangerous mechanism of injury (great height, road traffic accident)
  • Have evidence of coagulopathy (including anticoagulation with warfarin).

YEAR 4 - ACC (11 decks)

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