RTS- ENT

Question 1

List the eye and ear conditions you may come across in community pharmacy (13)

Answer 1

1) eye infections
2) eye allergies
3) dry eyes
4) subconjunctival haemorrhage
5) macular degeneration
6) cataracts
7) styles
8) blepharitis
9) earache
10) superficial infection of outer ear
11) ear wax
12) tinnitus
13) vertigo

Question 2

List the symptoms associated with bacterial conjunctivitis (6)

Answer 2

1) both eyes infected( but one eye usually infected first by 24-48 hours)
2) discharge - purulent ( sticky , yellow/green) glued together in the morning
3) pain /discomfort- gritty feeling
4) distribution of redness generalises and diffused
5) normally no other associated symptoms
6) duration 2-3 days

Question 3

List the symptoms associated with viral conjunctivitis (6)

Answer 3

1) both eyes infected
2) discharge- watery
3) pain/discomfort- gritty feeling
4) distribution of redness generalised
5) other symptoms include cough and cold symptoms
6) 1-2 weeks duration

Question 4

List the symptoms associated with allergic conjunctivitis (6)

Answer 4

1) both eyes affected
2) watery discharge
3) pain/ discomfort - itching
4) distribution of redness generalised
5) associated symptoms- allergic rhinitis symptoms, worse at particular times of day
6) duration variable

Question 5

Outline the symptomatic management of eye infections (4)

Answer 5

1) bacterial vs viral - different treatments
2) no specific treatment for viral - self limiting , refer is no improvement, cold/hot compress and dry eye , eye drops may help .
3) propamidine (brolene drops) , could help with bacterial conjunctivitis, especially for those who cannot use chloramphenicol
4) 1 or 2 drops up to QDS for two days

Question 6

Outline the use of chloramphenicol to treat bacterial conjunctivitis (5)

Answer 6

1) only licensed to treat bacterial conjunctivitis for > 2years , not licenses for contact lens wearers, regardless of it they are wearing contact lenses right now
2) patient must describe symptoms of sticky eyes, itchy or gritty, usually one eye to confirm symptoms of bacterial infection
3) not to be used for people with blood discrasias or medicines that affect the bone marrow
4) drops-‘s day TX , 1st 48 hours 1-2 drops every 2hours , remaining 72 hours QDS
5) ointment- apply up to QDS for five days

Question 7

Outline the non-pharmacological advice to give to patients with acute bacterial conjunctivitis (5)

Answer 7

1) bathing the eyelids with tepid water to remove any discharge
2) when cleaning the eye , wipe the eye from the bridge of the nose to the outer corner of the eye with a fresh piece of cotton wool or gauze
3) avoid sharing towels or facecloths as eye infections are easily passed on to other people
4) useful to discuss with the patient the possible cause of bacterial conjunctivitis and advise on the conditions self limiting nature ( will clear within 1-2 weeks without any treatment)
5) use OTC lubricant eye drops to help reduce discomfort in eyes

Question 8

Outline the symptomatic management of allergic conjunctivitis (4)

Answer 8

1) systemic antihistamines
2) sodium cromoglicate eye drops- mast sell stabiliser- suitable for children > 12 years up to QDS
3) sympathomimetics - acts like decongestants to dry up secretions, xylometazoline. Short term use 5 days . >5 years CL if patient is on a MAOI e.g phenelzine
4) antihistamine eye drops e.g. Antazoline, can raise pressure Of eye - CL in glaucoma

Question 9

Outline when you would refer a patient with an eye problem (12)

Answer 9

1) pain within the eye
2) visual disturbance- blaring or mark in field of vision
3) abnormal or uneven pupils
4) upper eyelid drooping
5) babies- under three months or with a squint
6) existing eye disease/ already on eye drops
7) recurring complaint
8) bulging eyes , especially unilateral
9) treatment failure - especially if had antibiotic drops before
10) blocked tear duct
11) contact lens wearers
12 suspected foreign body in the eye

Question 10

Outline the red flag symptoms (urgent referral) for patients with eye problems (8)

Answer 10

1) eye or head injury
2) painful eye movements
3) vision is affected - painful eye movements and severe pain within the eye
4) photophobia
5) acute glaucoma , where the patient is suffering from severe nausea
6) eye surgery or laser treatment in the past six months
7) pupil looks unusual i.e torn, irregular, dial aged or sluggish , non reactive to light
8) eye looks cloudy

Question 11

Outline the points to consider when treating patients with eye problems. (3)

Answer 11

1) age can affect product choice
2) treatment choice also affected by contact lens use
3) pregnant and breastfeeding women and special patient groups

Question 12

What is macular degeneration?

Answer 12

A disorder Of the macular - the part of the retina that contains central vision, tends to develop with age so often known as age- related MD. Causes progressive loss of central and detailed vision

Question 13

What is subconjunctival haemorrhage and how is it treated (6)

Answer 13

Burst blood vessels , self - limiting

1) tends to happen spontaneously, sometimes associated with sneezing , blowing nose
2) red areas on the eye with no other symptoms
3) harmless but causes patient a lot of concern
4) no treatment required, slowly fades over few weeks
5) check if on warfarin (anticoagulant) /asprin/BP?
6) refer if recurrent

Question 14

What is dry eye? And how is it treated (6, 1)

Answer 14

Tear deficiency can cause discomfort in eyes

1) aggravated by dry air, dust, wind and smoke
2) patients with thyroid problems may have dry eye
3) bilateral symptoms - discomfort, soreness, irritation, grittiness
4) refer if not previously seen by Dr
5) needs treatment to prevent damage to epithelial cells and complications e.g. Ulceration of the eye
6) medicine induce dry eye include - anticholinergic drugs e.g. Antihistamines, TCAs , HRT , diuretics

7) treated with moisturisers - “ artificial tears” - hypromellose, caemellose, paraffin bases, carbomer , acetylcysteine , polyvinyl alcohol

Question 15

Outline the two main types of macular degeneration (2)

Answer 15

1) wet MD is when abnormal blood vessels group behind the macular and leak fluid, pushing the macular away from its blood supply and results in rapid loss of vision - refer immediately
2) dry MD is when deposits build up behind the macular - affects vision slowly , no cure but some high dose vitamin and mineral supplements available to maintain eye health e.g. Preservision original tablets and viteyes original

Question 16

Explain what cataracts is and outline the treatment options (5)

Answer 16

1) clouding of the lens of the eye
2) makes vision blurred or dim as light cannot pass through the lens
3) bright lights such as car headlights may be dazzling, some discomfort when moving from shade to sunlight , glasses/ contact lenses don’t improve vision
4) tinted glasses or new prescription glasses may help initially
5) affected lens can also be removed surgically and replaced with an artificial lens

Question 17

Explain what stye is, outline the symptoms and treatment options (6)

Answer 17

1) bacterial infection of hair follicle at the base of the eye lash
2) symptoms : irritation, soreness and pain, redness, initial swelling of eye lid but reduces to a head , with a small pustule at the tip
3) treatment: should resolve in few days, if symptoms do not improve or worsen , or very painful should go see GP
4) apply a warm compress (e.g. Using a clean flannel that has ben rinsed in hot water) to the affected eye for 5-10 minutes. Repeat three to four times daily until the stye drains or resolves.
5) avoid excessively hot compress to avoid scalding
6) they should not attempt to puncture an external stye themselves

Question 18

Explain what blepharitis is and outline the symptoms (3)

Answer 18

1) chronic inflammation of the eyelid margins
2) symptoms : affects both eyes , lids become red and raw , some inflammation and itchy and uncomfortable. May be some scaling and the flaking of skin cells. Eye lashes may fall out
3) can be caused by staphycoccal infection , allergic dermatitis or known as seborrhoeic blepharitis- normally associated with oily skin and dandruff of scalp and eyebrows

Question 19

Outline the treatment for blepharitis (6)

Answer 19

1) first line treatment is washing with diluted baby shampoo 1part baby shampoo to 10 parts water
2) a warm compress may loosen crusts
3) may cause dry eyes which need to be treated
4) if antibiotics needed- should be prescribed by GP
5) avoid eye make up
6) if there is no response redder as it can result in ulceration. Also lost eyelashes re-grow in different directions including inwards towards the eye , which may cause conjunctivitis and corneal damage

Question 20

Outline the cautions you must take with patients wearing contact lenses (5)

Answer 20

1) some eye drops can affect contact lenses
2) some systemic drugs can affect contact lenses e.g. Rifampicin and sulfasalazine can colour contact lenses
3) contact lens wearers may be susceptible to different types of eye infections
4) if asked about lubricating eye drops for use with contact lenses- check product carefully to make sure it is suitable
5) if asked about contact lens solutions - if in doubt refer to opticians

Question 21

Outline the WWHAM for otitis externa

Answer 21

Inflammation of the skin of the pinna or external ear canal. May be caused by fungus, bacteria and fungus

Who- patients who have frequent or prolonged exposure to water are more prone- often known as swimmers or surfers ears

What- inflammation, irritation, itching , may be sis charge and pain of varying severity

How long - chronic forms > 3 months, duration of symptoms depends on cause

Action- have they been treated already?

Medication - recent treatment with steroid / antibiotic drops?

Other - hearing aid? Cotton buds? Ear plugs ? Hairspray/hair dyes/ shampoos? Immunosuppression?

Question 22

Describe the symptomatic treatment of earache (otitis media) (3)

Answer 22

1) requires referral for antibiotics
2) pain relief is the only thing that could be supplied OTC to treat
3) referral is essential for children

Question 23

Outline the WWHAM for a earache (otitis media)

Answer 23

Who - in adults, tends to be part of upper respiratory infection (URTI), common in young children - children have to be referred

What- pain inside the ear . If associated with URTI in adults no need to refer unless pain is severe and not improving after 48 hours. Fever and general malaise may be present as a sign of infection. Dizziness - ears control balance

How long? - over 48 hours in adults refer , children will start complaining within 24 hours , refer immediately

Action - pain relief already taken? Antibiotics?

Medication- ototoxic drugs - tend to be antibiotics or immunosuppressants

Question 24

Describe the symptomatic treatment of otitis externa (5)

Answer 24

Most cases require referral for steroid and/or antibiotic ear drops

1) mild otitis externa can be treated with OTC acetic acid (earcalm) spray , only for > 12 years , refer if no improvement in 48 hours.
2) aluminium acetate is an anti infective
3) cliquinol with steroid anti infective and anti inflammatory
4) avoid triggers
5) paracetamol for pain

• avoid irritants by using ear plugs or cotton wool coated in soft white paraffin when showering or bathing

Question 25

Outline the WWHAM for ear wax (5)

Answer 25

Cerumen (oil produced by ears) combines with epithelial cells in canal to form waxy protective layer. When too much cerumen is produced a obstructive waxy plus can form

1) who- check for allergies can affect product choice
2) what - gradual deafness, some discomfort , itching and dizziness
3) how long- gradual onset tends to be recurrent
4) action already taken? Has it been diagnosed? Has the patient tried to clean ears, this is often leads to impaction. Not for pharmacists to make diagnosis. What products work?
5) medication - ototoxic medicines?

Question 26

Outline the symptomatic treatment of ear wax (7)

Answer 26

1) treatments know as cerumenolytics act to loosen, soften and dissolve wax
2) oils e.g. Olive , almond etc - check nut allergies
3) sodium bicarbonate solution - softener, may cause dryness in ear
4) glycerol - softener
5) docusate- facilitate water penetration to loosen wax
6) urea hydrogen peroxide- urea aids penetration of drops, hydrogen peroxide reacts with catalase in wax producing bubbles which loosen up the wax
7) parachlorobenzene and chlorobutanol assist penetration of oils

Question 27

Explain how to apply ear drops (6)

Answer 27

1) it is easiest to put ear drops lying down, preferably with help from someone else.
2) turn your head to one side , with the infected ear uppermost
3) squeeze the correct number of drops carefully into the ear canal
4) stay with your head turned on one side for 1 to 2 minutes (check packaging) so that the drops can be absorbed properly
5) gently press the flap at the front of the ear to help the drops of right down the ear canal
6) repeat at dosage intervals and for the course length stated on packaging of as directed by doctor

• cotton buds should be used to remove perceived ear wax . Do not leave cotton wool in ear to prevent debris from ear being removed

Question 28

Describe how may drops to apply for the ear, nose and eyes

Answer 28

Eyes- one drop
Nose - two (2-3) drops
Ears- three (3-4) drops

Question 29

What is tinnitus and what are the symptoms (6)

Answer 29

1) tinnitus is the unwanted perception of sound, within the persons head, in the absence of sound from the external environment
2) it may be described as ringing , hissing, buzzing, roaring or humming
3) can be subjective or objective
4) subjective tinnitus is when only the patient can hear the disturbance
5) objective tinnitus can be heard by the patient and the person examining them.
6) refer patient

Question 30

What is vertigo and what are the symptoms and treatment (5)

Answer 30

1) the perception of spinning or rotation of the person or their surroundings in the absence of any actual physical movement
2) it is a symptom not a diagnosis
3) symptoms of conditions such as Ménière’s disease and migraines
4) caused by altered activity in the balance organs- peripheral vertigo or disturbance in communication between the visual and vestibular centres in the brainstem and cerebellum
5) refer if not related to migraine

Question 31

List when you would refer a patient to the doctor (15)

Answer 31

1) pain
2) deafness
3) vertigo
4) tinnitus
5) blocked ears
6) discharge
7) foreign body in ear
8) bleeding
9) nausea/ vomiting
10) neck stiffness
11) any injury
12) treatment failure
13) history/suspicion of perforated eardrum
14) problems with balance
15) abnormal lesion/blister/ulcer