Ophthalmology and ENT Flashcards
Acoustic neuroma
Presentation and the cranial nerves involved
V: Absent corneal reflex
VII: Facial nerve palsy - if tumour grows big enough to compress facial nerve
VIII:
- Unilateral hearing loss
- Unilateral tinnitus
- Dizziness/imbalance
- Fullness in the ear
Describe HiNTs test and implications
HI = Head Impulse
- Peripheral = abnormal
- Central = normal
N = Nystagmus
- Peripheral = unidirectional or none (fast component is away from the affected side)
- Central = vertical, bidirectional, gaze-evoked
TS = Test of Skew
- Peripheral = no skew deviation
- Central = skew deviation
Ototoxic drugs
Permanent:
- Vancomycin, Gentamicin, Streptomycin
- Cisplatin
Temporary:
- Quinine
- Macrolides (clari, eryth, azithro)
- NSAIDs
- Aspirin
- Loop diuretics
All cause BILATERAL hearing loss and tinnitus
Otosclerosis
- genetics
- what is it
- when do people get it
- treatment
- Autosomal dominant
- New bone forms around stapes footplate –> fixation
- Accelerated by PREGNANCY
- Tx = hearing aid, surgery
Investigation for sudden sensorineural hearing loss
- MRI scan to exclude schwannoma
- Audiology –> Loss of 30 decibels in 3 consecutive frequencies
BPPV
Management
- Self-limiting usually
- Epley maneuver
- Betahistine
Acoustic neuroma
Management
Risk of Tx
- Conservative: monitoring
- Surgery: partial or total removal
- Radiotherapy
Tx risks : vestibulocochlear nerve damage, facial nerve damage
Vestibular neuronitis
Management
Acute:
- Prochlorperazine (PO) or antihistamine for milder symptoms
- Prochlorperazine (buccal/IM) for severe
- For up to 3 days - any longer may slow recovery
Chronic:
- Refer if not improving after 1 week or does not resolve after 6 weeks
- May need vestibular rehabilitation
Labyrinthitis
Management
Acute:
- 3 days of Prochlorperazine or antihistamines
- If bacterial –> Abx
Offer audiology after recovery
Generally only have long-lasting symptom if post-bacterial meningitis
Meniere’s Disease
Management
- Inform the DVLA
Acute:
- Prochorperazine (buccal/IM)
- Antihistamines
Prophylaxis:
- Betahistine
Nasal polyps
Samters triad
- Nasal polyps
- Asthma
- Aspirin sensitivity
Nasal polyps
Red flags
- Unilateral
- Bleeding
Nasal polyps
Management
- Refer to ENT to exclude malignancy
- Topical corticosteroids - drops or spray
- Surgery:
- Intranasal polypectomy if visible and close to nostril
- Endoscopic intranasal polypectomy if further in or sinuses
Mastoiditis
Management
- IV Ceftriaxone OD + IV Metronidazole TDS
- Consider topical therapy, e.g. Ciprofloxacin ear drops
- Myringoplasty (repair of tympanic membrane - if ruptured)
- Mastoidectomy (eradicated cause of chronic infection, removes mastoid air cells, retains posterior canal wall)
Otitis media
Management
- Usually self-limiting
Immediate Abx IF:
- Immunocompromised
- Significant co-morbidities
- Systemic features
- Bilateral and < 2 yrs
- < 3 months of age
- Perforation +/- discharge
- > 4 days of symptoms with no improvement
Abx = Amoxicillin
If penicillin allergy -> Clarithromycin
If Pregnant and allergy –> Erythromycin
Otitis media
Most common cause
- Strep pneumonia
Tonsillitis
Management
If viral:
- Analgesia, safety net, consider delayed prescription
If Abx required:
- 7-10 days of phenoxymethylpenicillin (penicillin V)
- Clarithromycin if PA
Tonsillitis
FeverPAIN score
Fever (> 38) P: Purulent exudate A: Attended within 3 days of onset I: Inflamed tonsils (severely) N: No cough/coryza
Tonsillitis
CENTOR criteria
- Fever > 38
- Exudative tonsils
- TENDER cervical lymphadenopathy
- No cough
Quinsy
Management
- Urgent ENT referral
- Needle aspiration and drainage
- IV Abx
- Consider tonsillectomy if recurrence
Otitis externa
Management
Mild:
- Acetic acid (Ear Calm) = antifungal and antibacterial
- Can be used prophylactically pre-swim
Mod:
- Topical Abx and steroid
- e.g. Otomize = Neomycin, dexamethasone and acetic acid
- Alternatives: gentamicin and hydrocortisone, ciprofloxacin and dexamethasone, neomycin and betamethasone
- Do NOT use in perforation tympanic membrane (higher risk of ototoxicity)
Severe:
- Ear wick with aluminum acetate
- Oral Abx: Flucloxacillin/clarithromycin
Fungal –> clotrimazole
Malignant otitis externa
Pathophysiology
- Extension of infection into bony ear canal and soft tissues deep in bony canal
Malignant otitis externa
Risk factors
- Diabetes
- Immunosupressants
- HIV
- Old age
Malignant otitis externa
Symptoms
- Severe otitis externa pain
- Headaches
- Fever
Malignant otitis externa
Key finding
Granulomatous tissue at the junction between bone and cartilage
Malignant otitis externa
Management
- Admission to hospital under ENT
- IV Abx
- In diabetes: CIPROFLOXACIN to cover pseudomonas
- Imaging: CT/MRI
Most likely location of anterior nosebleed?
- Kiesselbach’s plexus in LITTLE’S AREA
little fingers picking noses
Nosebleeds
Management
Haemodynamically stable
- Basic first aid, lean forward, mouth open, hold cartilaginous area for 10-20 mins. Spit out any blood
- Naseptin (chlorhexidine and neomycin) QDS for 10 days to reduce crusting, inflammation and infection
(CI in peanut, soy or neomycin allergy)
Nosebleeds
Management
When to admit to hospital
- Not stopped after 10-15 mins
- Bleeding from both nostrils
- Haemodynamically unstable
- Comorbidity (CAD, severe HTN)
- Underlying cause is suspected
- < 2 yrs old - leukaemia/haemophilia more likely
Nosebleeds
Hospital management
CAUTERY - If the source of bleed is visible
- Anaesthetic spray
- Silver nitrate for 3-5 seconds
- Only cauterize one sign
- Dab clean and use naseption
PACKING - If the source of bleed is not visible
- Or used if cautery is not viable
- Topical anesthetic spray
- Pack nose with head forward
If fail all above:
- Surgical sphenopalatine ligation
Obstructive sleep apnoea
RFs
- Macroglossia (acromegaly, hypothyroidism, anyloidosis)
- Large tonsils
- Marfan’s Syndrome
- Middle age, male, obesity, smoking, alcohol
Obstructive sleep apnoea
Investigations
- Epworth sleepiness scale
- Multiple sleep latency test - time to fall asleep in dark room
- Sleep studies - polysomnography
Infectious mononucleosis
Investigation
- Heterophile antibody test (monospot test)
- FBC
- Do in 2nd week of illness
- 100% specific but 70-80% sensitive as not everyone with IM produces these antibodies and can take up to 6 weeks to build up
Infectious mononucleosis
Management
- Usually self-limiting
- No contact sports for 8 weeks - risk of splenic rupture
- No drinking alcohol (EBV affects livers ability to process)
Differentiating tonsillitis and infectious mononucleosis?
- Tonsillitis: anterior lymphadenopathy
- IM: anterior AND posterior lymphadenopathy
Infectious mononucleosis
Reaction to be aware of
- Itchy maculopapular rash in response to Amoxicillin or Cephalosporin or Ampicillin
Rhinosinusitis
Management
Acute (< 12 weeks):
- If not improving after 10 days offer MOMETASONE (high dose steroid nasal spray)
- Delayed Abx if worsening/not improving within 7 days
Chronic (> 12 weeks):
- Saline nasal irrigation
- Avoid allergen
- Functional endoscopic sinus surgery
- Steroid nasal sprays - mometasone or fluticasone
Rhinosinusitis
Red flags
- Unilateral
- Persistent symptoms despite compliance with 3 months of Tx
- Epistaxis
Refer to ENT
What should you do when referring someone for hoarseness?
- Arrange a CXR to rule out apical lung lesion
Adie pupil
Tonically dilated pupil, slowly reactive to light with more definite accommodation response. Caused by damage to parasympathetic innervation of the eye due to viral or bacterial infection. Commonly seen in females, accompanied by absent knee or ankle jerks.
Marcus-Gunn pupil
Relative afferent pupillary defect, seen during the swinging light examination of pupil response. The pupils constrict less and therefore appear to dilate when a light is swung from unaffected to affected eye. Most commonly caused by damage to the optic nerve or severe retinal disease.
Horner’s Syndrome (pupil)
Miosis (pupillary constriction), ptosis (droopy eyelid), apparent enophthalmos (inset eyeball), with or without anhidrosis (decreased sweating) occurring on one side. Caused by damage to the sympathetic trunk on the same side as the symptoms, due to trauma, compression, infection, ischaemia or many others.
Hutchinson’s sign
Unilaterally dilated pupil which is unresponsive to light. A result of compression of the occulomotor nerve of the same side, by an intracranial mass (e.g. tumour, haematoma)
Argyll-Robertson pupil
Bilaterally small pupils that accommodate but don’t react to bright light. Causes include neurosyphilis and diabetes mellitus
Gingival hyperplasia
Causes
- Phenytoin
- Ciclosporin
- CCBs - esp nifedipine
- AML
