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Final Year - ICSM > Opthalmology & ENT > Flashcards

Opthalmology & ENT Flashcards

1
Q

Diabetic retinopathy stages?

A

Diabetic retinopathy: retinal screen annually (age ≥12yrs)

  • Background: need to tighten control
    • Venodilation, microaneurysms (dots), hard exudates (lipid deposits)
    • Tx: tighten glycaemic control, refer if near macula
  • Pre-proliferative (mild) - soft exudates (cotton wool spots e.g. infarcts)
  • Proliferative - neovascularization (+ floaters, reduced acuity)
    • Tx: pan-retinal photocoagulation
  • Diabetic maculopathy - hard exudates, oedema (+ blurred vision, reduced acuity)
    • Tx: intravitreal triamcinolone acetonide decreases macula oedema
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2
Q

Eye problem 1st line Ix?

A

Fundoscopy

  • Innitially:
    • General inspection
    • Pupil size, symmetry, shape, colour
    • Next darken room + give mydriatic eye drops (tropicamide 1%) + ask to look straight ahead
  • If assessing right eye hold in right hand
  • Use diopter dial to make sure looks sharp
  • Check red reflex (fundal reflex) at distance of arm’s length - light reflecting from vascularised retina
    • Absent = cataracts, vitreous haemorrhage, retinal detachment, retinoblastoma (in kids)
  • Fundus
    • Optic disc - assess edges (if blurred = papilloedema)
    • Assess retinal vessels & macula
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3
Q

Dendritic pattern on fluorescein stained cornea

A

Herpes simplex ulcer

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4
Q

Young female, very high BMI, on OCP with headaches

A

Check for papilloedema –> idiopathic intracranial HTN

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5
Q

White fluid level in anterior chamber of eye

A

Hypopyon

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6
Q

Sudden loss of vision DDx?

A
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7
Q

Central retinal artery occlusion RFs? The most common cause? Presentation? Mx?

A

Cause: temporal arteritis

RFs:

  • Male, older
  • Smoking, DM, HTN, high cholesterol

Presentation: acute, painless, monocular vision loss + RAPD

  • Fundoscopy - ischaemic retinal whitening + “cherry red spot” in centre

Mx: intra-arterial thrombolysis, reducing IOP by anterior chamber paracentesis, Acetazolamide & ocular massage

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8
Q

Central retinal artery occlusion vs branch retinal vein occlusion? The most common cause of each?

A
  • Whitening if arterial, darkening if vein

Causes:

  • Vein occlusion cause = myeloma
  • Artery occlusion cause = temporal arteritis
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9
Q

Pigment in anterior vitreous on fundoscopy?

A

Schaffer sign of retinal detachment

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10
Q

Pale retina without a cherry-red spot on fundoscopy

A

Ophthalmic artery occlusion

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11
Q

Visual blurring made worse by heat

A

Optic neuritis (Uhthoff’s phenomenon - MS)

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12
Q

Temporary black sheet moving down over eye is called? What is this associated with?

A

Amaurosis fugax - transient vision loss

Carotid artery stenosis –> predictive indicator for future stroke

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13
Q

Epistaxis - RFs? Where do most nosebleeds arise from? When is it a posterior bleed? Mx of anterior nosebleed?

A

RFs:

  • alcohol intake/excess
  • bleeding/clotting disorder
  • anticoag/platelets
  • topical drugs (decongestants, cocaine)
  • nasal polyps
  • chronic sinusitis

Location: anterior nasopharynx - Little’s area (where 5 arteries come together = Kiesellbach’s plexus)

  • NOTE: Posterior nose bleeds are less common but bleed more

Most anterior, suspect posterior bleed if:

  • Profuse bleed, both nostrils
  • The bleeding point can’t be seen on speculum exam
  • Suspected anterior bleed not responsive to packing/cautery
  • Mx posterior with bilateral posterior packing + abx (change packing every 48hrs)

Ix: nasal speculum examination

Mx of anterior nosebleeds:

  • First aid:
    • Sit up + lean forward
    • Mouth open (spit blood out)
    • Pinch nasal cartridge for 15mins
  • Vasoconstrictors (oxymetazoline spray, adrenaline-soaked gauze) & analgesia
  • Silver nitrate cautery (or electrocautery)
  • Anterior nasal packing
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14
Q

Chinese ethnicity, fascial pain, double vision, persistent lymphadenopathy

A

Nasopharyngeal carcinoma

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15
Q

Young child, recurrent epistaxis, purpuric lesions on fingertips/tongue

A

Hereditary haemorrhagic telagiectasia

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16
Q

Evolving sunburn-like erythema + confusion after >48hrs nasal packing

A

Toxic shock syndrome

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17
Q

Meniere’s disease - Sx? Dx? Ix? Mx?

A

Hallmark Sx = Meniere’s triad:

  • Intermittent vertigo –> ‘drop attacks’
  • Hearing loss (unilateral)
  • Tinnitus
    • sensitivity to loud noises

Dx:

  • ≥2 episodes of spontaneous vertigo 20m-12hrs
  • Fluctuating aural Sx (hearing, tinnitus, fullness)
  • Audimetrically sensory neural hearing loss in the affected ear around time of vertigo episode

Ix: thorough Hx + neuro exam + audiometry

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18
Q

DM + persistent otalgia despite abx - Dx?

A

Malig otits media (inf)

19
Q

Progressive hearing loss + aural fullness + persistent foul smell - Dx?

A

Cholesteatoma

20
Q

Tonsilitis - most common causes? scoring? Ix? Mx? When to ADMIT?

A

Causes: EBV, GAS

Scoring:

  • CENTOR (if <3 days pharyngitis):
    • Cough absent
    • Exudate
    • Nodes (cervical anterior)
    • Temp >38 at any point
  • FeverPAIN score
    • Fever (during previous 24 hours)
    • Purulence (pus on tonsils)
    • Attend rapidly (within 3 days after onset of symptoms)
    • Severely inflamed tonsils
    • No cough or coryza

Ix: oropharyngeal examination (unless considering epiglottitis - can cause respiratory compromise –> keep child calm with mum/dad)

Mx:

  • If CENTOR 3-5/FeverPAIN 4-5 –> rapid strep test + abx (phenoxymethylpenicillin) + self-care advice
  • Otherwise just self-care advice (if FeverPAIN 2-3 can give ‘back-up abx’)
  • Tonsillectomy if: 7 bouts in 1yr/5 bouts per year for 2yrs/3 bouts per year for 3yrs

ADMIT if:

  • Difficulty breathing
  • Clinical dehydration
  • Peri-tonsillar abscess (quinsy)/cellulitis
  • Marked systemic illness/sepsis
  • Suspected rare cause (e.g. Kawasaki disease, diphtheria)
21
Q

Bilateral cervical lymphadenopathy, fever, myalgia, testicular pain - Dx?

A

Mumps

22
Q

Acrid/bitter taste in mouth while eating, pain in parotid/submandibular region - Dx?

A

Salivary duct stones

23
Q

Hypertensive retinopathy grading?

A

Grade 1: arteriolar narrowing + silver wiring

Grade 2: AV nipping

Grade 3: flame-shaped haemorrhages + cotton wool spots

Grade 4: papilloedema = raised ICP –> CT-scan

24
Q

Conjunctivitis - breakdown & organism causes?

A

Mx bacterial: topical azithromycin

  • Viral/allergic - topical antihistamine e.g. epinastine
25
Q

Acute angle-closure glaucoma - presentation? Ix? Mx?

A

Presentation: blurring of vision, painful red eye, headache, N&V

  • In contrast:
    • Uveitis has small pupil (& red eye, headache & visual disturbance)
    • Scleritis, corneal ulcer and conjunctivitis are not associated with headache and nausea or sign drop in visual acuity

Ix:

  • Gonioscopy - examination of anterior chamber angle
  • Slit-lamp examination
  • Automatic static perimetry

Mx:

  • 1st line - Carbonic anhydrase inhibitors (acetazolamide) AND/or topical beta-blockers (timolol) AND/or topical alpha-2 agonists (brimonidine)
    • When the suspected cause is pupillary block/plateau iris syndrome and IOP <40 –> topical ophthalmic anticholinergic (pilocarpine)
    • Initial Tx fails/IOP >50 –> hyperosmotic agent (IV mannitol)
  • 2nd line - anterior chamber paracentesis
  • Surgery (after acute attack resolves in pupillary block)/chronic angle-closure glaucoma - laser peripheral iridotomy
26
Q

How should you Mx sudden sensorineural hearing loss?

A

Refer to ENT in <24 hours, high dose PO prednisolone

27
Q

Sinusitis - red flags? When to admit? Ix? Mx?

A

Red flags (need urgent ENT referral):

  • Unilateral
  • Persistent > 3 months despite Tx
  • Epistaxis

When to admit:

  • Severe systemic infection
  • Signs of dangerous complications of sinusitis:
    • Periorbital/orbital cellulitis
    • Meningitis
    • Brain abscess

Ix: anterior rhinoscopy, nasal endoscopy

Mx:

  • If symptoms <10 days –> advice and safetynetting
  • If symptoms >10 days –> 14-day course of high-dose nasal CS
  • Can give back-up prescription of abx
28
Q

Sx of nasal polyps? What is Samter’s triad? Red flags?

Mx?

A

Sx:

  • Watery anterior rhinorrhoea, sinusitis
  • Snoring, headaches, nasal obstruction

Samter’s triad:

  • Nasal polyps
  • Asthma
  • Aspirin hypersensitivity
  • NOTE: if has nasal polyps and asthma –> advise to avoid NSAIDs & aspirin –> life-threatening reaction

Red flags: single, unilateral

Mx:

  • Routine referral to ENT for exam
  • Medical: 4-6w course of topical steroids
  • Surgically: can be removed endoscopically
29
Q

What does Diptheria look like?

A

Pseudomembranous ‘web’ at back of throat

30
Q

What is the main RF for tonsilar SCC?

A

HPV infection

31
Q

What is this a typical history for?

“an indurated ulcer involving the lateral tongue in a patient with a long-term smoking history”

A

SCC

32
Q

Causes of red eye?

A

Painless red eye:

  • Conjunctivitis:
    • Diffuse conjunctival injection (unilateral or bilateral)
    • Discharge (purulent if bacterial), swollen conjunctiva (chemosis) and debris
  • Subconjunctival haemorrhage:
    • Flat, bright red patch on conjunctiva with sharply defined borders and normal conjunctiva surrounding it.
  • Episcleritis:
    • Sectoral area of subconjunctival injection (unilateral)
    • Superficial - moveable with swab (using topical anaesthesia)
  • Dry eye:
    • Deficiencies in tear production/maintenance secondary to e.g. blepharitis (obstruction of meibomian glands)
    • Clinical features - diffuse conjunctival injection (unilateral/bilateral), inflamed lid margins with crusting & matted eyelashes.

Painful red eye:

  • Scleritis:
    • Localised conjunctival injection (unilateral), minimal watery discharge
    • Visual acuity may be reduced, photophobia, tender globe (causing the patient to wake at night) –> all progressively worsen
    • Commonly have CTD
  • Uveitis:
    • Circumciliary conjunctival injection (unilateral), hazy cornea, distorted pupil, hypopyon, watery discharge
    • Reduced visual acuity, photophobia & pain
  • Corneal abrasion:
    • Eye redness, pain, watering and photophobia
    • Epithelial defects stain brightly with fluorescein drops & cobalt blue light.
    • Damage to epithelial layer of eye due to light trauma - very painful but shortlived
  • Corneal ulcer:
    • Pain, watering, photophobia, staining epithelial defect with associated haziness (infiltrates)
    • Epithelial defect may appear fluffy, irregular and apparent even without a slit lamp.
    • More common in contact-lens wearers (infection or immunological response) = more severe than abrasion
  • Acute angle-closure glaucoma (AACG):
    • Significant pain –> vomiting, circumciliary conjunctival injection (unilateral), reduced visual acuity, photophobia, haloes in vision, hazy cornea and a mid-dilated unreactive pupil.
  • Foreign bodies:
    • May be visible on the surface of the eye or embedded within the cornea or sclera
    • Associated clinical features include redness, pain, watering and a ‘foreign body sensation’.
    • Foreign bodies may be hidden under the top and bottom of the eyelid.
33
Q

Retinal detachment - RFs? Presentation? Ix? Mx?

A

RFs:

  • Rhegmatogenous RD (small tear in retina - vitreous can get behind retina): prev Hx in other eye, prev cataract surgery, myopia (short-sighted), ocular trauma (e.g. lattice degeneration)
  • Non-rhegmatogenous RF: DM, intraocular tumour, age-related macular generation

Presentation:

  • Acute loss/deterioration of central vision
  • Flashing lights in temporal visual fields (easier to notice in dark environment)
  • Floaters (large, central)
    • Numerous, small = retinal haemorrhage

Ix:

  • Visual acuity testing
  • Slit-lamp exam
  • Indirect ophthalmoscopy

Mx:

  • Prophylactic Tx - laser cerclage
  • Retinal tear without detachment:
    • Asymptomatic - observation/reassurance ± prophylactic Tx (laser cerclage)
    • Symptomatic - cryopexy/laser retinopexy
  • Scleral buckle/vitrectomy + cryopexy/laser retinopexy
34
Q

Painful eye + loss of acuity - initial Mx?

A

Urgent opthalmological assessment

35
Q

Young adult complains of sore throat, fever, and malaise and also has lymphadenopathy and pharyngitis. Also palatal petechiae.

Dx? Ix?

A

Infectious mononucleosis (EBV)

Ix: EBV specific antibodies

36
Q

Red flags of neck lump?

A
  • Age >35
  • Hard fixed mass
  • Hoarseness/change in voice
  • Dysphagia
  • Trismus
  • Unilateral ear pain
  • Mucosal lesion
37
Q

Branchial cyst - def? presentation? Ix? Mx?

A

Def - a remnant of second branchial clefts

  • Congenital abn, presents 10-40yrs during inf
  • Can form fistula tracts - pass between internal & external carotids –> drain into tonsillar fossa

Presentation: painless rounded swelling in the anterior triangle (below the angle of mandible, anterior to SCM)

Ix: USS, CT/MRI

Mx: conservative ± surgical excision

38
Q

Borders of the anterior and posterior triangles of neck?

A

Anterior triangle:

  • Midline of neck
  • Angle of mandible
  • SCM (medial edge)

Posterior triangle

  • SCM (lateral edge)
  • Clavicle (proximal border)
  • Trapezius
39
Q

Cystic hygroma (macrocystic lymphatic malformations) - def? presentation? Mx?

A

Def: endothelial-lined lymphatic cavities due to maldev of lymphatic & venous communications

Presentation:

  • Presents <2yrs w/ pain, dyspnoea, haemorrhage, inf
  • Located - left posterior triangle of neck & axilla
  • Assoc w/ Turner’s & Down’s syndrome, Trisomies, congenital cardial abn, foetal alcohol syndrome

Mx: surgical excision/injection w/ Strep pyogenes (GAS) antigen –> obliterates cavities

40
Q

Otoscopy process? Further Ix?

A
  • Speech test - whisper number in each ear while rubbing other
  • Weber’s & Rinne’s tests
  • Examine external auditory canal - ear wax, erythema, discharge, foreign bodies + mastoid (mastoiditis)
  • Tympanic membranes - colour (erythema), bulging/retraction, light reflex, perforation
    • Pull pinna upwards & outwards, hold otoscope in right hand for right ear

Further Ix:

  • Swabs for culture
  • Bloods - FBC, U&E, CRP
  • Imaging: CT-head/temporal bone (if concerns of complications)
41
Q

Otitis media - Def? Causative organisms? Red Flags?

A

Def: middle ear inf, most resolve without abx

  • Organisms: S. pneumo, H. influenzae
  • Causes bulging tympanic membrane
  • Acute suppurative otitis media (perforated ear drum): otalgia + discharge –> otalgia improves after discharge (pressure release)

Red flags:

  • Mastoiditis
    • Sepsis w/ post-auricular tenderness
    • Mastoid air space abscess
  • Facial palsy - due to oedema of facial nerve (rare)
  • Meningism/altered conscious state
42
Q

Peri-tonsillar abscess (Quinsy)

  • How to decide in need abx?
  • Red flags? Ix? Mx?
A

Decide if need abx based on tonsilitis CENTOR criteria

  • Swollen tonsil is not peritonsillar abscess

Red flags:

  • Epiglottitis - hoarse voice, dysphagia, fever - DO NOT EXAMINE AIRWAY
  • Peritonsillar abscess - trismus (reduced mouth opening), “hot potato voice”, unable to swallow saliva - admit for IV fluids

Ix: FBC, U&E, CRP, LFTs & glandular fever screen = Liverpool peritonsillar abscess score (LPS) ≥4

Mx:

  • IV dexamethasone, abx (BenPen)
  • Incision & drainage/aspiration of abscess under LA
43
Q

Acute red eye, hypopyon, intense photophobia - Dx?

A

Anterior uveitis

Final Year - ICSM (20 decks)

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