Opthalmology & ENT Flashcards
Diabetic retinopathy stages?
Diabetic retinopathy: retinal screen annually (age ≥12yrs)
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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)
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Proliferative - neovascularization (+ floaters, reduced acuity)
- Tx: pan-retinal photocoagulation
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Diabetic maculopathy - hard exudates, oedema (+ blurred vision, reduced acuity)
- Tx: intravitreal triamcinolone acetonide decreases macula oedema
Eye problem 1st line Ix?
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
Dendritic pattern on fluorescein stained cornea
Herpes simplex ulcer
Young female, very high BMI, on OCP with headaches
Check for papilloedema –> idiopathic intracranial HTN
White fluid level in anterior chamber of eye
Hypopyon
Sudden loss of vision DDx?
Central retinal artery occlusion RFs? The most common cause? Presentation? Mx?
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
Central retinal artery occlusion vs branch retinal vein occlusion? The most common cause of each?
- Whitening if arterial, darkening if vein
Causes:
- Vein occlusion cause = myeloma
- Artery occlusion cause = temporal arteritis
Pigment in anterior vitreous on fundoscopy?
Schaffer sign of retinal detachment
Pale retina without a cherry-red spot on fundoscopy
Ophthalmic artery occlusion
Visual blurring made worse by heat
Optic neuritis (Uhthoff’s phenomenon - MS)
Temporary black sheet moving down over eye is called? What is this associated with?
Amaurosis fugax - transient vision loss
Carotid artery stenosis –> predictive indicator for future stroke
Epistaxis - RFs? Where do most nosebleeds arise from? When is it a posterior bleed? Mx of anterior nosebleed?
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
Chinese ethnicity, fascial pain, double vision, persistent lymphadenopathy
Nasopharyngeal carcinoma
Young child, recurrent epistaxis, purpuric lesions on fingertips/tongue
Hereditary haemorrhagic telagiectasia
Evolving sunburn-like erythema + confusion after >48hrs nasal packing
Toxic shock syndrome
Meniere’s disease - Sx? Dx? Ix? Mx?
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
DM + persistent otalgia despite abx - Dx?
Malig otits media (inf)
Progressive hearing loss + aural fullness + persistent foul smell - Dx?
Cholesteatoma
Tonsilitis - most common causes? scoring? Ix? Mx? When to ADMIT?
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)
Bilateral cervical lymphadenopathy, fever, myalgia, testicular pain - Dx?
Mumps
Acrid/bitter taste in mouth while eating, pain in parotid/submandibular region - Dx?
Salivary duct stones
Hypertensive retinopathy grading?
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
Conjunctivitis - breakdown & organism causes?
Mx bacterial: topical azithromycin
- Viral/allergic - topical antihistamine e.g. epinastine
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
How should you Mx sudden sensorineural hearing loss?
Refer to ENT in <24 hours, high dose PO prednisolone
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
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
What does Diptheria look like?
Pseudomembranous ‘web’ at back of throat
What is the main RF for tonsilar SCC?
HPV infection
What is this a typical history for?
“an indurated ulcer involving the lateral tongue in a patient with a long-term smoking history”
SCC
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.
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
Painful eye + loss of acuity - initial Mx?
Urgent opthalmological assessment
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
Red flags of neck lump?
- Age >35
- Hard fixed mass
- Hoarseness/change in voice
- Dysphagia
- Trismus
- Unilateral ear pain
- Mucosal lesion
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
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
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
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)
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
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
Acute red eye, hypopyon, intense photophobia - Dx?
Anterior uveitis
