High Yield ENT Flashcards
A 22-year-old presents to the GP with difficulty breathing through his nose following a fistfight. During the fight, he sustained a blow to the face and fell to the ground, but denies losing consciousness. He has not experienced any vomiting or any other symptoms, except for difficulty breathing through his right nostril. On examination, there is a bruise around the right cheekbone and a red swelling arising from the right nasal septum.
What is the next most appropriate management?
Routine referral to ENT
Urgent referral to ENT
Follow-up in 1 week
CT head
Conservative measures i.e. cold compress
Urgent referral to ENT - nasal septal haematoma → needs urgent evacuation under GA w/ packing +/- suturing
causes of epistaxis
Causes include trauma, insertion of foreign bodies, bleeding disorders, angiofibroma, cocaine
Presentation = nose bleeding (usually unilateral), can also be vomiting
blood supply to the nose
Anterior
Most common
Nasal septum
Littles area (kiesselbachs plexus)
Posterior
Nasopharynx
Woodruff plexus
summary of management of epistaxis
Management
1. Position change and pinch for 20 mins
1. If bleed visible – silver nitrate cautery, if not – anterior nasal packing
1. If haemodynamically unstable or bleed not visualized admit to hospital
1. Sphenopalatine ligation in theatre
why can cocaine cause nose bleeds
cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.
why do we always need to exclude septal haematoma
Septal necrosis + nasal collapse if untreated
presentation of septal haematoma
- Nasal obstruction, pain, rhinorrhea
- Boggy swelling, soft & fluctuant palpation, asymmetry of septum w/ swelling
complications of septal ahematoma
septal abscess, septal necrosis + nasal collapse (saddle nose)
manaegemnt of septal haematoma
Mx by aspiration or drainage, suture, packing, Abx
- No need for XR if simple nasal # - cartilaginous injury won’t show & radiographs won’t alter Mx
- Ideally seen by ENT 5-10d post-injury
- Re-assess for deviation after 7d once swelling subsided – septoplasty 12m post-injury
- Only intervene if cosmetic deformity or nasal obstruction
- Needs reduction within 14d
A 6-year-old boy presents to the GP with his parents. He had a tonsillectomy 6 days ago and is recovering well, but they are worried after finding spots of blood on his pillowcase this morning. He has no other significant medical history. On examination, the boy appears well with no active bleeding, and observations are within normal limits.
What is the next most appropriate management?
Reassurance & discharge
Conservative measures i.e. cold compress
Routine referral to ENT
Urgent referral to ENT
Prescribe tranexamic acid
Urgent referral to ENT – always have low suspicion for post-op tonsillectomy hemorrhage esp. in kids!
FeverPAIN criteria or Centro
Offer antibiotics:
feverpain score 2 or 3
Centor 3 or 4
FeverPAIN
More accurate than Centor
- Fever
- Pus
- Attending early (within 3 days)
- Inflamed tonsils
- No cough
Centor criteria
Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)
Indications for ABx:
- Marked systemic upset
- RF Hx
- Increased risk from acute infection
- Centor/FEVER Pain score
- Unilateral peritonsillitis
- Give pen v or clarithro for 7-10d
Red flags/complications of tonsilitis
- Quinsy
- Tonsillitis
- Sinusitis
- Mastoiditis
- Otitis media
- Laryngitis
- Scarlet fever, RF
- Lemierre’s syndrome
- Epiglottitis
which antibiotics for tonsilitis
Penicillin V (also called phenoxymethylpenicillin) for a 10-day course is typically first-line. It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes.
Clarithromycin is the usual first-line choice in true penicillin allergy.
bacterial causes of sore throat
The most common cause: group A streptococcus (Streptococcus pyogenes). This can be effectively treated with penicillin V (phenoxymethylpenicillin).
The second most common bacterial cause of tonsillitis is Streptococcus pneumoniae.
Other causes:
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
summary of acute sore throat
Classic exam question: if give amox/ampicillin & develops macpap rash, think:
EBV
a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis
-> avoid contact sport for 6-8 weeks due to splenomegaly
Tonsillectomy Criteria:
Recurrent infection*…
* 7 ep. in 1 year
* 5 ep. for 2 years
* 3 ep. for 3 years
* Disabling & prevent normal functioning
Suspected malignancy
PSA/sleep disordered breathing in children
Recurrent quinsy
Severe immune deficiency
types of post-op tonsillectomy bleeds
Primary (<24hours)
Inadequate haemostasis
Secondary (>24 hr, usually 4-9d post-op)
Unclear aetiology – infection, fibrin clots, technique
management of post tonsillectomy bleed
Mx:
Always admit of Hx of blood
ABC + other measures
Examine throat
NOTIFY ENT REG***, involve paeds/anaesthetics early
A 59-year-old diabetic man sees his GP due to pain in his left ear. It has been there for the past 6 weeks, but in the last 2 weeks, he has been having ‘smelly white stuff’ coming out of his ear. He also complains about a headache around his left temporal area for the last few weeks not relieved by paracetamol.
On examination, he is apyrexial and neurological examination is normal. There is some creamy discharge in his left ear and on otoscopy, the walls are erythematous and sloughy. The tympanic membrane is normal.
Given the likely diagnosis, which of the following antibiotics will provide the best cover for the likely causative agent?
Amoxicillin
Gentamicin
Ciprofloxacin
Flucloxacillin
Metronidazole
Ciprofloxacin – OE in old diabetics → cover for Pseudomonas
otitis externa summary
History
- otalgia, pruritus, otorrhoea
Causes
- P.aueroginosa, S.aureus, candida, aspergillus
- moisture, trauma, absence of wax, dermatitis, swimming, hearing aids
Management
* Aural toilet (hoover out debris)
* ABx + steroid drops e.g. gentamicin
* KEEP EAR DRY
Necrotising/malignant OE
Temportal+ base of skull osteomyelitis - spread via the osseocartilaginous junction
- P.aueroginosa
Be aware the: diabetic, immunocompromised, elderly
Suspicious features
- Deep-seated pain, out of proportion
- Granulations
- Non-resolving OE
Other symptoms
- dysphagia
- hoarsness
- facila nerve dysfunction
Management
- admission
- CT scan
- IV abx e.g. ciprofloxacin
Complications
- Sinus thrombosis
- Meningitis
- Cerebral abscess
A 30yro woman presents to her GP with dizziness, nausea, and unilateral hearing loss which has been consistent for the past 2 days. Upon questioning, she denies having ever experienced symptoms like this before. She reports no tinnitus, otalgia or otorrhoea.
Upon examination, she is afebrile and does not appear to be in pain. Examination of her ears shows no abnormalities.
What is the most likely diagnosis?
Meniere’s disease
Benign Paroxysmal positional vertigo
Otitis media
Acute Labyrinthitis
Vestibular Neuronitis
Acute Labyrinthitis – pt has hearing loss + prolonged/constant vertigo
This patient has presented with symptoms of nausea, dizziness, and hearing loss. The likely diagnosis is labyrinthitis due to hearing loss. Labyrinthitis is inflammation of the labyrinth of the inner ear and presents with these symptoms and a sensorineural hearing loss.
acute lab vs vest neuronitis
Vestibular neuronitis is an inflammation of the eighth cranial nerve and presents similarly to labyrinthitis, however, it can be distinguished from the condition by the fact that vestibular neuronitis does not cause hearing loss.
conditions which cause vertigo
Peripheral causes
* BPPV
* Meniers
* Vestibular neuritis
* Labyrinthitis
* Acoustic neuroma
Central causes
* Cerebellar stroke: ~75% of them present with dizziness/vertigo
* Other: acoustic neuroma, ototoxic drugs, MS (not MND)
* Vestibular Migraine
* vertebrobasilar ischaemia – dizziness on neck extension
BPPV:
sudden onset, lasts secs, nystagmus, otolith, Dix-Hallpike +ive on affected side
Meniere’s:
endolymphatic hydrops, vertigo, EPISODIC mins-hours, aural fullness, low frequency HL, Fam Hx, Romberg’s +stepping test +ive, min
Vestibular neuritis:
inflammation of the vestibular nerve, severe, prolonged vertigo, N+V, viral infection HSV
Labyrinthitis:
Inflammation of inner ear, severe, prolonged vertigo, N+V, recent URTI
Acoustic neuroma
benign, neoplasm of vestibular nerve, unilateral, SN Hearing loss +/- facial palsy
causes of hearing loss
Sensorineural
- Presbycusis
- Labyrinthitis
- Acoustic neruoma
- Sudden sensorineural hearing loss
Conductive
- Otosclerosis
- glue ear
Drugs
- aminoglycoside
- furosemide aspirin
Webers: conductive
will localise to the affected ear
webers: sensorineural
will localise to unaffected ear
rinnes test: conductive
Bone conduction > air conduction
rinnes test: sensor
AC>BC
Presbycusis –
age related SN hearing loss, higher frequencies
Otosclerosis:
Autosomal dominant, replacement of normal bone by vascular spongy bone. Onset is usually at 20-40 years - features include:conductive deafness
tinnitus
tympanic membrane - 10% of patients may have a ‘flamingo tinge’, caused by hyperaemia
positive family history
labyrinthitis –
LOSS of hearing
+ vertigo, N+V, dizziness
A 32-year-old East Asian woman presents to A&E with a severe headache. It started suddenly when she was driving home last night and not relieved by simple painkillers. On examination, her left pupil is red and dilated. She has a past medical history of type 1 DM, asthma, and recently started amitriptyline for her fibromyalgia.
Considering the most likely diagnosis, what is the most appropriate management?
Topical antibiotics
Co-codamol and metoclopramide
High-flow oxygen and sumatriptan
Topical timolol
IV acetazolamide
IV acetazolamide – this patient likely has acute-angle closure glaucoma; acetazolamide > timolol due to Hx of asthma
why does acute angle closure gluacoma often occur at night
night due to iridocorneal angle reduction, reducing aqueous humour drainage
which drug class can cause acute closure
anticholinergics e.g. amitriptyline have anti-M effects thus pupil dilation also make it worse
AACG: A True Ophthalmic Emergency!
Symptoms
- Extremely painful red eye
- N&V
- Reduced acuity, blurry vision
Examination
- Cloudy cornea
- Fixed, dilated, irregular pupil
- Raised IOP → rock-hard
Mx: reduce IOP quick!!!
REFER TO OPHTHALMOLOGIST
Acutely…
- Lie flat on back
- Pilocarpine drops
- Topical B-blocker
- Acetazolamide IV
Long-term definitive → bilateral YAG peripheral iridotomy
red eye differentials: painful
1. Is there fluoresceine uptake
Yes:
- Keratitis
- corneal abrasion
2. No fluoresceine uptake: Is there raised intraocular pressure e.g. >24mmHh
Yes:
- AACG
No raised IOP: Is there consensual photopbia e.g. when light put close to eye
Yes: Anterior uveitis (think SLE)
No: scleritis
summary of red eye with no injury
scleritis vs episcleritis
Scleritis
- autoimmune
- Very painful
- DOES NOT BLANCHE WITH PHENYLEPHIRNE
- associated with RA, GPA, SLE
- management: systemic steroids/NSAIDs +- topical ABx
Episcleritis
- idiopathic ifnlammation
- NOT painful
- DOES BLANCH WITH PHENYLEPHRINE
- common
- usually idiopathic or : IBD, RA
A 35-year-old woman presents to the GP complaining that her vision is “like looking through a tube”. She occasionally experiences a moderate headache that is not eased by paracetamol. Her visual field assessment report during her routine appointment with the optometrist is shown below.
What other sign or symptom would you specifically ask about?
Limb weakness
New floaters
Weight loss
Increased thirst
Increasing hand size
Increasing hand size – this is a bitemporal hemianopia, classic of a pituitary adenoma, which present with gradual and progressive visual and/or endocrinological symptoms. In this case, GH adenoma → acromegaly
gradual vision loss causes
Diabetic retinopathy
Hypertensive retinopathy
Age Related Macula Degen
Cataracts
Open-angle glaucoma
Sudden loss of vision
- Optici neuritis
- Central retinal artery occlusion
- Central retinal vein occlusion
- Retinal detachment
- Posterior vitreous detachment
- Vitreous hameorrhage
- Transient
Optic neuritis
– Related to MS
Findings
- RAPD
- dyschromatopsia (colour blindness)
- unilat reduction in visual acuity
- pain worse w/ movement
Central retinal artery occlusion
Due to thromboembolisms or arteritis e.g. temproal arteritis
Findings
- unilat Loss of vision
- RAPD
- cherry-red spot on pale retina,
Emergency- treated like a stroke
central retinal vein occlusion
more common than artery
causes
- glaucoma, polycythaemia, hypertension
Presentation
- unilat Loss of vision
- RAPD
- stormy sunset appearance
- retinal haemorrhage can be seen
Retinal detachment
Features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters (see below)
* F Floaters (small dark spots on a bright background are generally harmless)
* F Flashes (migraine)
* F Field loss (dark cloud covers a field of vision)
* F Falling acuity (serious)
vitreous detachment, which may precede
retinal detachment,
- first signs are flashes of lights or floaters
Vitreous haemorrhage
– spectrum, DM or trauma, painless unilat LOV
- Flashes of light (photopsia)- in the peripheral field of vision
- Floaters, often on the temporal side of the central vision
posterior vitreus detachment vs retinal detachment
A PVD occurs when the vitreous pulls away from the retina. When a PVD occurs, bleeding can possibly occur and as the vitreous gel pulls away, it might cause holes or rip tears in the retina. A retinal detachment occurs when the retina is separated from the back of the eye wall.
Transient causes of vision loss
GCA, TIA, migraine, MS
ischaemic cause of transient loss of vision
‘Amaurosis fugax’
- wide differential including large artery disease (atherothrombosis, embolus, dissection), small artery occlusive disease (anterior ischemic optic neuropathy, vasculitis e.g. temporal arteritis), venous disease and hypoperfusion
- ischaemic optic neuropathy is due to occlusion of the short posterior ciliary arteries, causing damage to the optic nerve
- may represent a form oftransient ischaemic attack(TIA).
Presentation
- ‘curtaincoming down’
Management
- It should therefore be treated in a similar fashion, withaspirin 300mgbeing given
A 45-year-old presents to the GP with a painful right eye. He was hammering a metal block with a chisel and not wearing eye protection, and his right eye suddenly became painful and his vision is blurry. On examination, there is a small conjunctival laceration with some subconjunctival haemorrhage, but you cannot see any foreign body.
Following an urgent referral to the ophthalmologist, what would be the most appropriate investigation?
CT scan
MRI
Ultrasound
Fluorescein-staining slit-lamp
Plain XR
CT scan – high likelihood of metallic intraocular foreign body, XR or CT is fine
NOT MRI IF POTENTIALLY METAL
FOREIGN BODY & ABRASIONS symptoms
- FB sensation
- Watering
- Redness
- Photophobia
- Vision rarely affected
FOREIGN BODY & ABRASIONS investigations
Slit-lamp examination w/ fluorescein stain
If high-risk IO injury → **CT (not MRI if metallic body suspected) + to be seen by ophthalmologist
managemet of foreign body
Surface FB → irrigation or removal
Corneal abrasions → ABx ointment
IntraOcular FB → surgical removal
All need follow-up in 24 hrs
opthalmic abrasiaon management
Non contact wearer:
- An ophthalmic antibiotic ointment (eg, bacitracin/polymyxin B or ciprofloxacin 0.3% 4 times a day for 3 to 5 days) is used for most abrasions until the epithelial defect is healed.
- Contact lens wearers with corneal abrasions require an antibiotic with optimal antipseudomonal coverage (eg, ciprofloxacin 0.3% ointment 4 times a day).
For symptomatic relief of larger abrasions (eg, area > 10 mm2), the pupil is also dilated once with a short-acting cycloplegic (eg, one drop cyclopentolate 1% or homatropine 5%).
Prognosis The corneal epithelium regenerates rapidly; even large abrasions heal within 1 to 3 days. A contact lens should not be worn until the injury is healed.
Advice for people with superficial corneal injuries
- Wearing sunglasses or staying out of areas of bright light may help with symptoms of light sensitivity.
- Advise the person on suitable eye protection to prevent injury in the future and provide patient information.
- The eye should not be touched or rubbed and contact lenses should be avoided while the eye recovers.
A 29-year-old man attends A&E with a 1-week history of pain in his right ear. He has not seen his GP prior to this as he thought it would resolve with simple painkillers. On examination, you find his right ear is bulging outwards and the skin behind it is erythematous and swollen. He is afebrile.
What is the most appropriate management for the likely condition?
PO steroids
IV antibiotics
PO antibiotics
PO antibiotics and PO steroids
IV antibiotics and PO steroids
Mastoiditis
IV antibiotics – given for 1-2d, then stepped down to PO
You are the F1 in GP doing a telephone consultation with a 31-year-old woman who is too dizzy to see you at the surgery. She woke up this morning feeling very dizzy, describing the sensation as the room spinning. Apart from ‘a bit of a cold’ a few days ago, she is otherwise fit and well.
Given the likely diagnosis, how should you manage the patient?
Prochlorperazine in the acute phase
Betahistine in the acute phase – little evidence
Prochlorperazine for the duration of the illness – interferes with central compensatory mechanisms
Betahistine for the duration of the illness – little evidence
Vestibular rehab exercises – for chronic symptoms
Prochlorperazine in the acute phase – give for a few days only; if vomiting, give IM
