Headache + ENT Flashcards
What is meningococcal disease?
Meningococcal septicaemia
OR
Meningococcal meningitis
Or a combination of both
What are the main causes of bacterial meningitis?
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
What are some non-infective causes of meningitis?
Malignant cells Drugs - NSAIDs, trimethoprim Sarcoidosis SLE Behcet's disease
What are some early features of meningitis?
Headache Fever Leg pains Cold hands and feet Abnormal skin colour
What features make up ‘meningism’?
- 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
How would meningitis present in an infant?
High-pitched cry
Bulging fontanelle
Vomiting
Drowsiness
What indicates invasive meningococcal disease?
- Petechial rash that is non-blanching (use glass test to check)
- Signs of shock: prolonged cap refill, hypotension, tachycardia
What investigation should you do first in suspected meningitis?
Blood cultures
After taking blood cultures, how is meningitis managed?
- 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)
What is the blind/empirical therapy for meningitis?
IV ceftriaxone (3rd generation cephalosporin)
If atypical pathogens, add IV amoxicillin
If Listeria, add gentamicin
What antibiotic should GPs give to treat meningitis in the community?
IM benzylpenicillin
What should be given as prophylaxis to those in close-contact with meningitis?
Rifampicin
What complications can arise from meningitis?
Immediate complications:
- DIC
- Raised ICP
- Pericardial effusion
Delayed complications:
- Encephalopathy
- Hearing loss
Describe the CSF analysis in bacterial, viral + TB meningitis
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 ++++
What is the most common focal neuropathy with a space occupying lesion?
CN VI palsy - most common as it has long intracranial path
What causes temporal arteritis?
Autoimmune vasculitis affecting the posterior ciliary arteries
Who should you always consider temporal arteritis in?
All patients over 50 years with a recent sudden onset headache
What condition is temporal arteritis associated with?
Polymyalgia rheumatica
How does temporal arteritis present?
Headache Scalp tenderness e.g. when combing hair Tongue/jaw claudication - pain on chewing Amaurosis fugax - transient visual loss Sudden unilateral blindness
What is the risk with temporal arteritis?
Irreversible bilateral visual loss - can occur suddenly if not treated so emergency refer to ophthalmologist
What are some extracranial symptoms of temporal arteritis?
Malaise Dyspnoea Weight loss Morning stiffness Unequal or weak pulses
How does the retina appear in temporal arteritis?
Pale papilloedema
Pale, waxy, elevated disc = ischaemia
Splinter haemorrhages
What bloods must be done in temporal arteritis?
ESR - raised >47
CRP - raised
What provides a definitive diagnosis of temporal arteritis?
Temporal artery biopsy - within a week of starting steroids
What is the treatment for temporal arteritis?
Start prednisolone 60mg OD immediately to avoid visual loss
If there is visual loss/history of amaurosis fugax - IV methyprednisolone
What presents similarly to subarachnoid haemorrhage?
Venous Sinus Thrombosis
What is venous sinus thrombosis?
Acute thrombosis (blood clot) in the dural venous sinuses (which normally drain blood from the brain) causing cerebral infarction
Which sinus is most commonly affected by venous sinus thrombosis?
- Sagittal sinus thrombosis
2. Transverse sinus thrombosis
What are the risk factors for venous sinus thrombosis?
Prothrombotic haematological conditions (thrombophilia)
Hormonal factors (pregnancy, COCP, peri-partum period)
Local factors (sinus infection, trauma, skull abnormalities)
Systemic disease (malignancy, dehydration, sepsis)
What is the onset of symptoms like in venous sinus thrombosis?
Gradually come on over days or weeks
How does venous sinus thrombosis present depending on the sinus affected?
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
What often causes cavernous sinus thrombosis?
Spread from facial pustules or folliculitis
What imaging is done for venous sinus thrombosis?What would you see on the imaging?
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
How do you treat venous sinus thrombosis?
LMWH to anticoagulate
Then start warfarin to reach INR 2-3
If unresolved, give thrombolysis or mechanical thrombectomy
When is a mechanical thrombectomy futile?
Large infarcts
Impending herniation
Name some triggers of migraines
CHOCOLATE
Chocolate Hangovers Orgasms Cheese/caffeine Oral contraceptives Lie-ins Alcohol Travel Exercise
What precedes the headache in a migraine?
Prodromal symptoms
- Hours/days
- Yawning
- Cravings
- Sleep or mood changes
What types of aura may occur during a migraine?
Aura
- Visual
- Somatosensory - paraesthesiae
- Motor - dysarthria, ataxia, hemiparesis
- Speech - dysphasia
Describe the headache in a migraine. What associated symptoms present with the headache?
Headache
- Unilateral, pulsating headache
- Can wake patient in the night
Associated symptoms
- Nausea + vomiting (only once or twice)
- Photophobia, phonophobia
What is the prophylactic treatment of migraines?
- Propanolol
- Amitryptiline
- 12 weekly botulinum toxin injections in chronic migraines
How do you treat a migraine during an attack?
- Simple analgesic with anti-emetic e.g. paramax = combination preparation
of ibuprofen + prochlorperazine - Triptans = 5-HT1 (serotonin) receptor agonist
What usually causes otitis media?
Viral URTI - adenoid pads enlarge and block off eustachian tube
Who commonly presents with otitis media?
Children aged 3-6 years, following URTI
How does otitis media present?
Earache and deafness
Fever
Discharge is a later sign associated with a decrease in pain due to perforated tympanic membrane
What test identifies the side of the hearing loss?
Weber’s test
- Conductive hearing loss = loudest in affected ear
- Sensorineural hearing loss = quieter in affected ear
How can you distinguish between whether it is a conductive or sensorineural hearing loss?
Rinne’s test - if the tuning fork is perceived louder on the mastoid process, there is a conductive hearing loss
When should you treat otitis media with antibiotics?
Perforation
Bilateral otitis media
Infants below age of 2
What is the first line antibiotic for otitis media?
Amoxicillin
What is a complication of otitis media?
Mastoiditis - boggy swelling behind the ear, pushes the ear forward
What most commonly causes bacterial tonsillitis?
Group A beta-haemolytic streptococcus
What else can cause purulent exudate in the throat?
Epstein Barr Virus
What criteria is used to predict whether tonsillitis has a bacterial cause?
Centor criteria
- Tonsillar exudate
- Anterior cervical lymphadenopathy
- Temperature > 38
- Absence of cough
If >2 consider treating with antibiotics
What investigation can be done if EBV is suspected?
Monospot test
What antibiotics are used to treat bacterial tonsillitis?
1st line - PO phenoxymethylpenicillin 500mg QDS for 10 days (unless allergic)
2nd line - clarithromycin
What should you never prescribe for tonsillitis?
Amoxicillin
If it were EBV, it would cause all over body rash
What is a complication of tonsillitis?
Quinsy = peritonsillar abscess
What is the cardinal feature of encephalitis?
Altered mental status - this is less prominent in meningitis
What is the most common cause of encephalitis?
Herpes simplex virus type 1
Aside from altered mental status, how might encephalitis present?
Flu-like prodromal symptoms
Fever
New seizures
What is the gold standard investigation for suspected encephalitis?
LP with CSF sent for viral PCR
What is the best imaging modality for suspected encephalitis?
MRI (because CT head often appears normal acutely)
What is the typical distribution of herpes simplex encephalitis?
Temporal distribution
What is the management of suspected encephalitits?
Treatment should be initiated while awaiting definitive diagnosis of the condition as the progression of HSE is very rapid
- Immediate IV acyclovir 10mg/kg TDS for 2 weeks
- Broad spectrum antimicrobial cover with 2g IV ceftriaxone BD
- Supportive management of complications e.g. anticonvulsants for seizures
What is a side effect of acyclovir that must be monitored for? How do you minimise the risk of the side effect
Nephrotoxicity - acyclovir can crystallise in the glomeruli
Manage with adequate hydration and dose tapering
What is the criteria for head CT after head injury (as recommended by NICE)?
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).
