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High Yield ENT Flashcards

1
Q

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

A

Urgent referral to ENT - nasal septal haematoma → needs urgent evacuation under GA w/ packing +/- suturing

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2
Q

causes of epistaxis

A

Causes include trauma, insertion of foreign bodies, bleeding disorders, angiofibroma, cocaine
Presentation = nose bleeding (usually unilateral), can also be vomiting

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3
Q

blood supply to the nose

A

Anterior
Most common
Nasal septum
Littles area (kiesselbachs plexus)
Posterior
Nasopharynx
Woodruff plexus

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4
Q

summary of management of epistaxis

A

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

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5
Q

why can cocaine cause nose bleeds

A

cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.

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6
Q

why do we always need to exclude septal haematoma

A

Septal necrosis + nasal collapse if untreated

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7
Q

presentation of septal haematoma

A
  • Nasal obstruction, pain, rhinorrhea
  • Boggy swelling, soft & fluctuant palpation, asymmetry of septum w/ swelling
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8
Q

complications of septal ahematoma

A

septal abscess, septal necrosis + nasal collapse (saddle nose)

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9
Q

manaegemnt of septal haematoma

A

Mx by aspiration or drainage, suture, packing, Abx

  1. No need for XR if simple nasal # - cartilaginous injury won’t show & radiographs won’t alter Mx
  2. Ideally seen by ENT 5-10d post-injury
  3. Re-assess for deviation after 7d once swelling subsided – septoplasty 12m post-injury
  4. Only intervene if cosmetic deformity or nasal obstruction
  5. Needs reduction within 14d
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10
Q

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

A

Urgent referral to ENT – always have low suspicion for post-op tonsillectomy hemorrhage esp. in kids!

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11
Q

FeverPAIN criteria or Centro

A

Offer antibiotics:
feverpain score 2 or 3
Centor 3 or 4

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12
Q

FeverPAIN

A

More accurate than Centor
- Fever
- Pus
- Attending early (within 3 days)
- Inflamed tonsils
- No cough

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13
Q

Centor criteria

A

Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)

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14
Q

Indications for ABx:

A
  • Marked systemic upset
  • RF Hx
  • Increased risk from acute infection
  • Centor/FEVER Pain score
  • Unilateral peritonsillitis
  • Give pen v or clarithro for 7-10d
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15
Q

Red flags/complications of tonsilitis

A
  • Quinsy
  • Tonsillitis
  • Sinusitis
  • Mastoiditis
  • Otitis media
  • Laryngitis
  • Scarlet fever, RF
  • Lemierre’s syndrome
  • Epiglottitis
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16
Q

which antibiotics for tonsilitis

A

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.

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17
Q

bacterial causes of sore throat

A

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

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18
Q

summary of acute sore throat

A
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19
Q

Classic exam question: if give amox/ampicillin & develops macpap rash, think:

A

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

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20
Q

Tonsillectomy Criteria:

A

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

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21
Q

types of post-op tonsillectomy bleeds

A

Primary (<24hours)

Inadequate haemostasis

Secondary (>24 hr, usually 4-9d post-op)

Unclear aetiology – infection, fibrin clots, technique

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22
Q

management of post tonsillectomy bleed

A

Mx:
Always admit of Hx of blood
ABC + other measures
Examine throat
NOTIFY ENT REG***, involve paeds/anaesthetics early

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23
Q

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

A

Ciprofloxacin – OE in old diabetics → cover for Pseudomonas

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24
Q

otitis externa summary

A

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

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25
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
26
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.
27
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.
28
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
29
BPPV:
sudden onset, lasts secs, nystagmus, otolith, Dix-Hallpike +ive on affected side
30
Meniere's:
endolymphatic hydrops, vertigo, EPISODIC mins-hours, aural fullness, low frequency HL, Fam Hx, Romberg's +stepping test +ive, min
31
Vestibular neuritis:
inflammation of the vestibular nerve, severe, prolonged vertigo, N+V, viral infection HSV
32
Labyrinthitis:
Inflammation of inner ear, severe, prolonged vertigo, N+V, recent URTI
33
Acoustic neuroma
benign, neoplasm of vestibular nerve, unilateral, SN Hearing loss +/- facial palsy
34
causes of hearing loss
Sensorineural - Presbycusis - Labyrinthitis - Acoustic neruoma - Sudden sensorineural hearing loss Conductive - Otosclerosis - glue ear Drugs - aminoglycoside - furosemide aspirin
35
Webers: conductive
will localise to the affected ear
36
webers: sensorineural
will localise to unaffected ear
37
rinnes test: conductive
| Bone conduction > air conduction
38
rinnes test: sensor
AC>BC
39
Presbycusis –
age related SN hearing loss, higher frequencies
40
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
41
labyrinthitis –
LOSS of hearing + vertigo, N+V, dizziness
42
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
43
why does acute angle closure gluacoma often occur at night
night due to iridocorneal angle reduction, reducing aqueous humour drainage
44
which drug class can cause acute closure
anticholinergics e.g. amitriptyline have anti-M effects thus pupil dilation also make it worse
45
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
46
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
47
summary of red eye with no injury
48
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
49
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
50
gradual vision loss causes
Diabetic retinopathy Hypertensive retinopathy Age Related Macula Degen Cataracts Open-angle glaucoma
51
Sudden loss of vision
- Optici neuritis - Central retinal artery occlusion - Central retinal vein occlusion - Retinal detachment - Posterior vitreous detachment - Vitreous hameorrhage - Transient
52
Optic neuritis
– Related to MS Findings - RAPD - dyschromatopsia (colour blindness) - unilat reduction in visual acuity - pain worse w/ movement
53
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
54
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
55
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)
56
vitreous detachment, which may precede
retinal detachment, - first signs are flashes of lights or floaters
57
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
58
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.
59
Transient causes of vision loss
GCA, TIA, migraine, MS
60
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 of transient ischaemic attack (TIA). Presentation - 'curtain coming down' Management - It should therefore be treated in a similar fashion, with aspirin 300mg being given
61
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
62
FOREIGN BODY & ABRASIONS symptoms
* FB sensation * Watering * Redness * Photophobia * Vision rarely affected
63
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
64
managemet of foreign body
Surface FB → irrigation or removal Corneal abrasions → ABx ointment IntraOcular FB → surgical removal All need follow-up in 24 hrs
65
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.
66
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.
67
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
68
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

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