Loss of vision and ENT Flashcards
Painless sudden loss of vision
• Vitreous haemorrhage
• Optic neuritis
• Retinal detachment
• Wet Macular degeneration
• Central retinal vein occlusion
• Central retinal artery occlusion
• Central serous retinopathy
Vitreous haemorrhage
• Sudden painless loss of vision
• Caused by CRVO, proliferative diabetic retinopathy
• Symptoms- tadpoles, swirling, floaters or total visual loss
• PRP laser when clears or vitrectomy if doesn’t
Optic neuritis
• Sudden painless loss of vision
• Young, often female
• Red-desaturation, pain on movement, uni/bilateral, recurrent, usually resolves over 2 months
• Caused by MS or post infection
• Neuro referral, IV steroids if disabling visual loss
Retinal detachment
• Sudden painless loss of vision
• Myopes, trauma
• Flashes, floaters, curtains, shadows
• Urgent if macula still on or has just come off
Wet macular degeneration
• Sudden painless loss of vision
• >50
• Sudden onset, distortion, or central vision scotoma
• Needs urgent referral for OCT/IVFA and anti-VEGF as necessarily
Central serous retinopathy
• Painless sudden loss of vision
• Young men, type A
• Fluid under retina, increased hypermetropia
• Self-limiting, recurrent, usually no treatment
Central retinal vein occlusion
• Painless sudden loss of vision
• Risk factor- cardiovascular, smokers, obese, BP, DM, MI, CVA
• Haemorrhage, oedema, cotton wool spots, swollen disc
• Ischaemic/non-ischaemic
• Treatment- Ozurdex, anti VEGF, PRP laser
Central retinal artery occlusion
• Painless sudden loss of vision
• Risk factors- cardiovascular, smokers, obese, BP, DM, MI, CVA
• If its within 24 hours- rebreathing paper bag, ocular massage, then Diamox +/- paracentesis
• Refer to a stroke clinic asap
Anterior ischaemic optic neuropathy
• Arteritic or non arteritic
• GCA- old, unwell, weight loss, jaw claudication, scalp tenderness, headache
• ESR, CRP, platelets, temporal artery biopsy
• Admit IV steroids, then oral for at least 2 years. 2nd eye is at risk if 1st not treated promptly
Swollen optic disc
• Decreased vision, loss of colour vision, enlarged blind spot, RAPD
• Papilloedema,
• Optic neuritis
• Ocular tumours
• Hypermetropia, Hypotony
• Idiopathic intracranial hypertension
• Optic nerve head drusen
• CRVO
• Malignant hypertension
• Anterior ischaemic optic neuropaphy
Papilloedema
• Swollen optic disc
• Raised ICP
• Risk factors- tumour, haemorrhage, aneurysm, reduced CSF drainage, meningitis
• Visual obscurations, enlarged blind spot, headache, nausea, vomiting, usually bilateral disc swelling, dilated vessels, haemorrhages, cotton wool spots (cws), no RAPD other neuro signs/symptoms, VI nerve palsy
• Needs urgent scan and treatment of cause
Idiopathic intracranial hypertension-eyes
• Swollen optic disc
• Commonest cause of papilloedema, obese young women,
• Normal neuro imaging and CSF, but high opening pressure
• Visual obscurations, headache, disc swelling
• Monitor fields and colour vision, Weight loss, Diamox, optic nerve sheath fenestration, shunts
Optic nerve head drusen
• Swollen optic disc
• 0.5% Caucasians, bilateral, become more apparent with age, lumpy disc appearance, absent cup, trifurcation of vessels, VA normal but can have field defects
• Can be diagnosed by ultrasound, or autofluoresnce.
Optic neuritis
• Swollen optic disc
• Variable sudden loss of vision, uni or bilateral, red desaturation, pain on movement, young females, other neuro symptoms?
• 50% MS, refer neuro, IV steroids if disabling loss
Central retinal vein occlusion (CRVO)
• Swollen optic disc
• Cardiovascularpaths
• Sudden loss of vision, RAPD, swollen disc, haemorrhages on disc and throughout retina, usually unilateral
• Ozurdex, Anti VEGF, PRP laser
Ocular tumours and Hypermetropia
Ocular tumours- causes a swollen optic disc. Tuberous sclerosis, Neurofibromatosis, Haemangioma, Melanocytoma, Giloma, metasteses
Hypermetropia- swollen optic disc, small crowded disc, no change in vision, asymptomatic. Swollen optic disc
Hypotony and malignant hypertension
Hypotony- swollen optic disc, decreased IOP, usually iatrogenic after surgery, no visual symptoms
Malignant hypertension- swollen optic disc, disc swelling, retinal haemorrhage. BP >220/120, refer medics urgently
Anterior ischaemic optic neuropathy
• Sudden loss of vision, usually unilateral
• Symptoms of GCA or cardiovascularparth
• RAPD, swollen disc, typically pale +/- peripillary haem and cotton wool spots
• Treat according to cause i.e. high dose steroids for GCA
Causes and risk factors of otitis externa
Bacterial/ fungal- Pseudomonas, Staphlococcus, Candida, Aspergillus
Risk factors- swimming, immunosuppression, diabetes
Symptoms of otitis externa
-Pain (otalgia)
- Itching
- Discharge
- Redness (erythema)
- Hearing loss (conductive)
- Eczematous dry skin
Otitis externa- investigations and management
Otoscopy, ear swab
Topical +/- oral antibiotics- Gentamicin / Ciprofloxacin drops
Topical steroids
Micro suction
Water precaution
Complications of otitis externa
Necrotising otitis externa- spread of infection to the surrounding bone, osteomyelitis of the temporal bone
Pina cellulitis- spread of infection to the surrounding soft tissue
Necrotising otitis externa (NOE)
Can cause
Intra-cerebral abscess
Cranial nerve palsy (VII-XII)
Venous sinus thrombosis
Meningitis
Encephalitis
Long term IV antibiotics- Meropenem/Tazocin
Mortality- 10%
Septum pathologies
Swollen septum- septum haematoma
Septum perforation- cocaine infection
Different causes of rhinosinusitis
Allergic- nasal mucosal inflammation secondary to airborne allergens. Intra-nasal steroids (4 weeks to work), antihistamine
Infectious- mainly viral (rhinovirus, influenza virus, adenovirus)
-bacterial (strep, haemophilus)
-can rarely progress to sinusitis/pneumonia
Vasomotor- following nasal injury, blocked/stuffy nose with clear discharge
Management of sinusitis
- Analgesics such as paracetamol, NSAID’s or weak opiates
- Limited use (3-5 days) of nasal decongestant such as Xylometozaline spray
- A steroid nasal spray such as fluticasone
- Saline nasal cavity irrigation
NICE recommends prescribing antibiotics if complications or immunocompromised or over 10 day duration
Sinusitis- red flags
Complications- orbital/bony/intracranial
Eyes- Periorbital swelling/erythema, visual changes (orbital cellulitis)
Severe frontal headache
Frontal swelling
Neurology- reduced conscious level, meningism
Orbital cellulitis
-Tracking of infection from nasal cavity to orbit via ophthalmic veins
-Severe cellulitis, expothalmos, painful eye movement, vision loss
- Ophthalmic emergency: Imaging (CT/MRI), IV Abx, surgery (joint ENT ophthalmology)
Cavernous sinus thrombosis
- Clot formation in the cavernous sinus (complication of sinusitis)
- Vision changes
- Exopthalmos
- Cranial nerve palsy: III (down and out), IV, VI, V (1 and 2)
Nasal polyps
- Often associated with chronic rhinosinusitis
- Usually bilateral
- Symptoms: blockage, altered sense of smell
- Investigation: FNE, CT
- Management: medical- intranasal steroids, oral steroids
surgical- polypectomy
Nasal tumours
Risk factors: >50 year old, male, woodworkers (dusty environment)
Persistent unilateral symptoms: Epistaxis/nasal blockage
Epistaxis
Nose bleeds- very common, usually mild and self limiting, can be severe and life threatening
Conservative management- pinch and lean forward, pressure, ice
Nasal packing
Cauterise with silver nitrate
Topical medication
Surgery- SPA litigation, anterior ethmoidal litigation
Vocal cords- stridor/hoarse voice
Hoarse voice- the vocal cords are far apart and lots of air can get through
Stridor- Lots of contact between the vocal cords
Differential diagnosis for sore throat
V (vascular)
I (infectious)- laryngitis, epiglottitis, supraglottitis
T (traumatic)- laryngitis, epiglottitis, supraglottitis
A (auto-immune)- myasthenia gravis
M (metabolic)
I (idiopathic/iatrogenic)- thyroid surgery, post-intubation
N (neoplastic)- intrinsic (laryngeal cancer) extrinsic (lung cancer, thyroid cancer)
C (congenital)- laryngeal web, vocal cord palsy
D (degenerative)- Parkinsons disease, MND
E (endocrine)
F (functional)- anxiety, fatigue, muscle tension dysphonia
How would you investigate a sore throat
- Fibroptic nasoendoscopy: visualising the larynx
-Imaging: CT head and neck
Treatment options for larynx cancer
- Surgical excision i.e. laryngectomy
- Chemoradiotherapy: side effects- permanent loss of voice, difficulty swallowing, fatigue
- Palliative care
Laryngeal malignancy
- Present with persistent dysphonia
- Later presentation: may be with upper airway obstruction: stridor, SOB, airway emergency
- Mostly squamous cell carcinoma
- More common in older males
- Associated with smoking and alcohol abuse
- Treatment: laser excision, radiotherapy, chemotherapy, surgery, partial/total laryngectomy
Head and neck malignancy NICE guidlines
-Persistent unexplained hoarseness
- Persistent unexplained dysphagia
- Persistent unexplained neck masses
- Persistent unilateral nasal obstruction, particularly when associated with purulent discharge
- Unexplained ulceration of oral mucosa (>3 weeks)
- Unexplained lip/oral cavity swellings
- All red or red and white patches of the oral mucosa
Causes of stridor
Extramural: tumour, abscess or haematoma in the neck
Intramural: tumour of the larynx, paralysis of the vocal cords, epiglottitis, subglottic stenosis
Intraluminal: foreign body, blood or secretions inside the airway
Management of stridor
- ABCDE
- High flow oxygen
- Nebulised adrenaline (5mg)
- High dose IV steroids i.e. 8mg dexamethasone
- Avoid instrumentation of mouth/airway until senior support with airway expertise arrives
Epiglottitis
- Inflammation of the epiglottis/supraglottis
- HIB
-Children 2-6 - Symptoms are rapid onset and include trouble swallowing which can result in drooling, changes to the voice, fever and an increased breathing rate, leaning forward and appearing grey
Epiglottitis management
Do not examine the mouth, take blood etc
- Possible nebulised adrenaline or steroids
- Immediate anaesthetic and ENT assessment
- Likely intubation required depending on degree of suspicion
- Broad spectrum antibiotics
- Steroids
Difference between a Laryngectomy vs tracheostomy
A tracheotomy is just a breathing hole in the neck, normally used to treat airway obstruction. Nothing is removed, and the airway is intact. A laryngectomy removes the entire voicebox so there is no connection between the throat and the windpipe (trachea). That hole is the laryngectomy patient’s only way to breath, and they must have another way to speak other than the voicebox. Trach alone can still speak.
Causes of a sore throat
- Viral (rhinovirus, adenovirus, parainfluenza, influenza) or EBV (glandular fever)
- Bacterial (streptococcus)
- Fungal (candida)
- Physical irritation
- Allergies i.e. hay fever
Tonsilitis
Should determine whether to give antibiotics based on the centor score (penicillin/amoxacillin)
Encourage to eat and drink
Tonsillectomy for recurrent tonsillitis
Glandular fever/ infectious mononucleosis
- EBV sore throat
- Diagnosed with IM screen (monospot)
- Check LFTs
- Examine for hepatosplenomegaly
- No contact sport
Indications for tonsilectomy
Recurrent tonsilitis
>7 in 1 year
>5/year for 2 years
>3/year for 3 years
Quinsy x2
Obstructive sleep apnoea
Neoplasia
Investigations into seizures
1) EEG- can support the diagnosis, perform after the second seizure
2) MRI brain
3) ECG- to exclude arrhythmias
4) Blood glucose- hypoglycaemia and diabetes
5) Blood culture, urine culture and lumbar puncture- sepsis, encephalitis or meningitis
Status epilepticus
A seizure lasting more than 5 minutes or 2 or more seizures without regaining consciousness in-between
Stages of migraine
Prodrome- mood changes, hunger, cravings, fatigue (24-48 hours)
Aura- (5-60 mins), usually visual (zig-zags) but can be sensory or motor
Headache- severe, throbbing/pulsating, unilateral but can be global. Aggravated by movement. By definition must be at least 4 hours
Headache management
Triptan i.e. sumatriptan (6mg)- use triptans less than 10 times a month to prevent medication overuse headache
Use analgesics but less then 10 times a month to prevent medication overuse headache
Examination for headache
Blood pressure
Fundoscopy- for papilloedema
Migraine prophylaxis`
Beta blockers- not in asthmatics
Topiramate- warn of teratogenicity
Accupuncture
Chronic daily headache
Chronic migraine- headaches occurring on 15 or more days per month for more then 3 months, which on at least 8 days per month, had the features of migraine headaches
Medication overuse- headaches occurring on 15 or more days per month developing as a consequence of regular overuse of headache medication (on 10 or more days per month) for more than 3 months
Consider sleep apnoea and temporomandibular joint dysfunction
Treatment- hot and cold patches, neck exercise
Treatment for cluster headache
- Sumatriptan (S/C) not oral
- House oxygen/ demand valve
- Verapamil
Cluster headache
Cannot lie still
Autonomic symptoms (droopy eyelid and watery)
Diurnal time
30 min duration
Periorbital/supraorbital eye
Central venous sinus thrombosis
- Can cause thunderclap headache or progressive headache over days/weeks, life threatening but treatable
- Risk factors related to virchows triad (blood stasis, change in vessel wall, change in blood composition)
- Can have symptoms related to increased ICP or focal damage from venous infarction/haemorrhage
- Most have high opening pressure on lumbar puncture
- check optic disc
- Treated with anticoagulant i.e. warfarin
Papillitis
Inflammation of the optic nerve head i.e. in MS
- Often unilateral
- Usually affects visual acuity
- Affects colour vision
- Painful eye movement-RAPD
Papilloedema
Disk swelling in the context of raised ICP
- Usually bilateral
- Unless late presentation does not tend to affect visual acuity, colour, painless, no RAPD
