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
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
3
Q
Dendritic pattern on fluorescein stained cornea
A
Herpes simplex ulcer
4
Q
Young female, very high BMI, on OCP with headaches
A
Check for papilloedema –> idiopathic intracranial HTN
5
Q
White fluid level in anterior chamber of eye
A
Hypopyon
6
Q
Sudden loss of vision DDx?
A
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
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
9
Q
Pigment in anterior vitreous on fundoscopy?
A
Schaffer sign of retinal detachment
10
Q
Pale retina without a cherry-red spot on fundoscopy
A
Ophthalmic artery occlusion
11
Q
Visual blurring made worse by heat
A
Optic neuritis (Uhthoff’s phenomenon - MS)
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
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
14
Q
Chinese ethnicity, fascial pain, double vision, persistent lymphadenopathy
A
Nasopharyngeal carcinoma
15
Q
Young child, recurrent epistaxis, purpuric lesions on fingertips/tongue
A
Hereditary haemorrhagic telagiectasia
16
Q
Evolving sunburn-like erythema + confusion after >48hrs nasal packing
A
Toxic shock syndrome
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
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
Acute angle-closure glaucoma - presentation? Ix? Mx?
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
How should you Mx sudden sensorineural hearing loss?
Refer to ENT in \<24 hours, high dose PO prednisolone
27
Sinusitis - red flags? When to admit? Ix? Mx?
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
Sx of nasal polyps? What is Samter's triad? Red flags?
Mx?
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
What does Diptheria look like?
Pseudomembranous 'web' at back of throat
30
What is the main RF for tonsilar SCC?
HPV infection
31
What is this a typical history for?
"an indurated ulcer involving the lateral tongue in a patient with a long-term smoking history"
SCC
32
Causes of red eye?
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
Retinal detachment - RFs? Presentation? Ix? Mx?
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
Painful eye + loss of acuity - initial Mx?
Urgent opthalmological assessment
35
Young adult complains of sore throat, fever, and malaise and also has lymphadenopathy and pharyngitis. Also palatal petechiae.
Dx? Ix?
Infectious mononucleosis (EBV)
Ix: EBV specific antibodies
36
Red flags of neck lump?
* Age \>35
* Hard fixed mass
* Hoarseness/change in voice
* Dysphagia
* Trismus
* Unilateral ear pain
* Mucosal lesion
37
Branchial cyst - def? presentation? Ix? Mx?
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
Borders of the anterior and posterior triangles of neck?
Anterior triangle:
* Midline of neck
* Angle of mandible
* SCM (medial edge)
Posterior triangle
* SCM (lateral edge)
* Clavicle (proximal border)
* Trapezius
39
Cystic hygroma (macrocystic lymphatic malformations) - def? presentation? Mx?
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
Otoscopy process? Further Ix?
* **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
Otitis media - Def? Causative organisms? Red Flags?
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
Peri-tonsillar abscess (Quinsy)
* How to decide in need abx?
* Red flags? Ix? Mx?
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
Acute red eye, hypopyon, intense photophobia - Dx?
Anterior uveitis
