Surgical Specialties Flashcards
Pelvic floor exercises better for which type of incontinence?
Stress incontinence
First line medication for urge incontinence
Oxybutynin
Tolteridone
Mirabegron
Which type of incontinence is due to overactive detrusor muscle?
Urge incontinence
Which medication can be used in stress incontinence?
Duloxetine
If conservative management for removal of kidney stone fails, which surgery is most likely?
Shock wave lithotripsy
- breaks stones into smaller pieces so that they can be passed
Detrusor overactivity is diagnosed by which investigation?
Urodynamics
Which type of incontinence is due to damage to the pelvic floor or urethral function?
Stress incontinence
Stress / urge incontinence has a better role for pharmacotherapy?
Urge incontinence
Mainstay of treatment for stress incontinence?
Pelvic floor exercises
First line treatment for urge incontinence
Bladder retraining (6 weeks)
First line treatment for stress incontinence
Pelvic floor exercises (3 months)
Who should not get oxybutynin?
Frail elderly women
Ring pessaries are used as non surgical management for?
Pelvic organ prolapse
Anti-muscarinic drugs and side effects
Oxybutynin, tolteridone
SE: anti-cholinergic (dry mouth, constipation)
When are urodynamics needed?
When there is diagnostic uncertainty
When there are plans for surgery
Sympathetics dilate/constrict the pupil
Dilate
Parasympathetics dilate/constrict the pupil
Constrict
Fixed pin point pupil makes you think
Opioid toxicity
Fixed dilated pupil makes you think pathology of which CN?
CN III
Blink reflex
- afferent arm
- efferent arm
Afferent arm : CNV1
Efferent arm : CNVII
Pupillary light reflex
- afferent arm
- efferent arm
Afferent arm : CN II
Efferent arm : CN III (constriction bilaterally)
Lacrimal gland is under sympathetic/parasympathetic control and is supplied by which CN ?
Parasympathetic
CN VII
Eye in “down and out” position. Which CN is most likely to be affected?
CN III
Blurred vision when going down stairs (looking down) and double vision. Which CN is most likely to be affected?
CN IV
How do you measure intra ocular pressure?
Tanometry
- measures how much force is required to indent into a patients eye?
- patient given LA
What produces aqueous humour?
Cilliary body
if you hear “arcuate scotoma” where is the pathology?
Retina
If you have a process where you’re losing ganglion cells in the eye, you will notice the effects in the periphery/middle first?
Periphery
An enlarging cup:disc ratio is a buzzword for which ophthalmology condition?
What does it actually mean?
Glaucoma
- raised IOP causes ganglion cells around the optic nerve to die –> as they die, see fewer of them -> get a larger cup
Increased risk of open angle glaucoma if you are short / long sighted?
Short sighted
Name 5 types of medication for glaucoma
Prostaglandin analogues Beta blockers Carbonic anhydrase inhibitors (acetazolomide) Parasympathomimetics (pilocarpine) sympathomimetics (adrenaline, alphagan)
Name the 2 types of medication for glaucoma which ‘turn off the tap’ i.e. reduce aqueous humour production
Beta blockers
carbonic anhydrase inhibitors
Carbonic anhydrase inhibitors - which preparation is better: oral tablet or topical drops?
Oral tablet more effective
First line medication type for glaucoma
Prostaglandin analogues
Usual order of treatment for glaucoma
1) prostaglandin analogues
2) + B-blocker / carbonic anhydrase inhibitor
3) + B-blocker + carbonic anhydrase inhibitor
4) laser surgery?
5) sympathomimetic or parasympathomimetic
6) surgery (trabeculectomy)
Increased risk of ACUTE closed angle glaucoma if you are short sighted / long sighted?
Long sighted
What presents more in the emergency setting
- open angle glaucoma
- closed angle glaucoma
Closed angle glaucoma
Thumping headache, sick, really unwell, visual loss, often red eye. Gets CT scan everything normal. Someone looks in eye - find abnormality. What is likely diagnosis
Acute angle closure glaucoma
Management of acute angle closure glaucoma
1) decrease IOP medically with IV acetazolomide (carbonic anhydrase inhibitor)
2) peripheral iridotomy (stop it from happening again)
What is the most worrying acute cause of raised intra ocular pressure
Acute angle closure glaucoma
treatment of bacterial conjunctivitis
Topical chloramphenicol
Bacterial / viral conjunctivitis is associated with tender pre-auricular lymph nodes?
Viral
Unilateral folicular conjunctivitis in a young patient. What do you need to consider?
Chlamydial conjunctivitis
Bacterial corneal ulcer (keratitis) investigation of choice
Corneal scrape
First line management of bacterial kertatitis
Ofloxacin (hourly drops)
Why should you be cautious of using steroids in patient with red eye?
If the cause is herpetic keratitis and the patient has a dendritic ulcer, steroids will cause geographical ulcer making it much harder to treat
Which is more common: episcleritis or scleritis
Episcleritis
Which is more serious: episcleritis or scleritis
Scleritis
Red eye (limbus) Acute onset Dull achey pain Vision may be reduced Photophobia Hypopyon What do these symptoms make you think of?
Anterior uveitis
Cloudy cornea Red eye Fixed mid dilated pupil Significantly reduced visual acuity. Makes you think?
Acute angle closure glaucoma
How does aqueous humour normally drain away?
Through the trabecular meshwork
Emergency first line management of acute angle closure glaucoma
IV acetazolamide - to reduce the IOP
What does pilocarpine do to the pupil?
Shrinks the pupil
Surgical treatment for closed angle glaucoma
Peripheral iridotomy
Myopia - short sighted or long sighted
Short sighted
High myopia can increase risk of what condition?
Retinal detachment
High hypermetropia can increase risk of what condition?
Acute angle closure glaucoma
What carries 2/3rds of the ability to focus in the eye?
Lens
What is the commonest cause of blindness in the elderly population?
ARMD
Patient with gradual decrease in central visual acuity and then one day wakes up with sudden dramatic decrease in visual acuity. What is the likely diagnosis?
Dry ARMD –> wet ARMD
Describe the pathogenesis of wet ARMD
New blood vessels created to ‘repair’ the damage made by dry ARMD.
These blood vessels leak fluid / blood into the retinal tissue
Cause sudden sharp decrease in central visual acuity
What is the best way to diagnose or monitor ARMD
OCT scan
Tenting of the retinal pigment epithelium on OCT suggests
wet ARMD
What is the best investigation to confirm the diagnosis of wet ARMD
fluorescene angiography
Management of wet ARMD
Anti VEGF injection
- inhibits the growth of new vessels -> decreased leakage
Name 4 causes of gradual visual loss
Cataracts
ARMD
Diabetic retinopathy
Open angle glaucoma
Name 5 causes of PAINLESS sudden visual loss
Central retinal artery occlusion Central retinal vein occlusion Amaurosis fugax Retinal detachment Vitreous haemorrhage
Name 3 causes of PAINFUL sudden visual loss
Acute angle closure glaucoma
Optic neuritis
Giant cell arteritis
TIA in the eye
Amaurosis fugax
Pale swollen retina with cherry red spot at macula
Central retinal artery occlusion
Sudden profound visual loss + temporal headache, scalp tenderness, jaw claudication what do you think?
Giant cell arteritis
Treatment of GCA
Long term steroids
Paper bag breathing causes increased/decreased pCO2 and therefore vasodilation/vasoconstriction of the arteries
Increased pCO2
Vasodilation
Management of CRAO
If presents within 12-24 hours
- occular massage (push to a branch)
- paper bag breathing
- IV acetazolamide
Which visual loss is more severe? CRAO or CRVO ?
CRAO
Stormy sunset
Cotton wool spots
Dilated torturous veins
What do you think
CRVO
What is a cotton wool spot
Ischaemia of the retinal nerve fibre layer
Sudden onset of flashing lights in the periphery
Burst of new floaters
Dark shadow in peripheral vision, increasing in size
makes you think
Retinal detachment
Which features of examination do you focus on when assessing optic nerve function
Visual acuity
Visual fields
Colour vision
Pupil responses - RAPD (swinging light reflex)
Unilateral optic disc swelling - what condition are you thinking about
OPtic neuritis
Bilateral optic disc swelling - what condition are you thinking about
Papilloedema
MS and which ophthalmic condition go hand in hand
Optic neuritis
Patient with optic neuritis, female, young. What investigation should you consider?
MRI
Sudden unilateral loss in vision over period of a few days, dull ache pain on eye movements, decreased colour vision in affected eye
optic neuritis
Bilateral optic disc swelling and raised ICP. What is first investigation and what are you looking for
MRI / CT scan to identify if there is a space occupying lesion
Bilateral optic disc swelling and raised ICP. Ix done but no space occupying lesion found…what could be the diagnosis now and what Ix should you do?
Idiopathic intracranial hypertension
Ix - Lumbar puncture
Lesion at optic nerve would do what to vision?
Unilateral visual loss (on same side as optic nerve damage)
Lesion at optic chiasm would do what to vision?
Bitemporal hemianopia
Lesion at optic tract / radiation would do what to vision?
Homonymous hemianopia
Lesion at visual cortex would do what to vision?
Cortical blindness, macula sparing
Mild ptosis (eyelid droop) Constricted pupil which does not dilate Reduced ipsilateral sweating
Horners Syndrome
Patient with double vision -> cover one eye and double vision disappears. This is monocular/binocular diplopia?
Binocular
Patient with double vision -> cover one eye and double vision remains indicates
Problem with that eye
- ie corneal problem or cataract
Monocular/binocular diplopia is seen with problems with eye movement (ie CN pathology)
Binocular diplopia
CN III palsy clinical findings (3)
Dilated pupil
Ptosis (eyelid droop)
Eye looks down and out
Patient with sudden loss of vision. What is it important to exclude?
GCA
Goinoscopy is used for
Glaucoma
What is the leading cause of blindness in working age people?
Diabetic retinopathy
What is the management of proliferative retinopathy
Later treatment (pan-retino-photocoagulation) ablate peripheral retina to preserve the central
A child’s visual system is constantly developing from birth until the age of
6
What is amblyopia?
Reduced vision usually in one eye due to a degraded retinal period so the brain doesn’t develop the binocular visual pathways
essentially a lazy eye
Causes of amblyopia?
Squint
Unequal refractive errors
Obstruction to visual axis: cataract, ptosis
How do you treat amblyopia?
Cover the good eye
Patch
Long sighted (hypermetropic) people have a tendency for eyes to point inwards/outwards?
Inwards
4 year old boy presents with 1 week Hx convergent squint and vomiting ++. What are you worried about?
Raised intra cranial pressure
Which CN palsy (3,4, or 6) makes you most worried about raised intra cranial pressure?
CN 6 palsy (esp if bilateral)
Patient with ?papilloedema - bilateral CN VI palsy - vomiting - swollen optic discs What is your investigation of choice?
Urgent CT
- look for dilated ventricles
Why should infant with no red reflex be referred urgently?
?retinoblastoma
Retinoblastoma is most common eye cancer in childhood. True or false?
True
What would an iris coloboma look like?
Think madelline mccann
Area of iris is missing
Key hole defect
Absent red reflex but instead a yellow reflex completely filling the pupil. What does this make you think of?
Retinoblastoma
14 month toddler, normal visual development up until 12 months, then stopped walking and was becoming more distressed, couldn’t see food on plate. What does this make you think?
Congenital cataract
What are the 2 main causes of sticky eyes in infancy?
Ophthalmia neonatorum (conjunctivitis occurring in first 28 days from birth)
Blocked nasolacrimal duct
Commonest cause of ophthalmia neonatorum
Picked up from maternal STI when passing through the birth canal
- gonococcal cause presents quickest
- chlamydial cause presents 2 weeks post birth
Management of ophthalmia neonatorum
Swabs
Azithromycin
Contact tracing for mother
Sticky + watery + white uninflammed eye from 2 months. What is likely diagnosis?
Blocked nasolacrimal duct
What investigation is done if ?blocked nasolacrimal duct?
Fluorescene dye
- should be seen in nostrils
- confirms diagnosis if the dye is picked up around the eye
Management of blocked nasolacrimal duct
DO nothing
- resist prescribing topical antibiotics
How are most convergent squints treated
Glasses
What is the likely diagnosis in a 21 year old male, with a longstanding female partner who presents with conjunctivitis and urethritis?
How would you treat this patient?
Reiters syndrome likely
antibiotics
How do you treat amblyopia if patient doesn’t tolerate patch?
Atropine 1% in good eye
Latent squint always affects both eyes. True or false?
True
Management of paediatric squint
Maximise visual acuity
- correct refractive error
- treat amblyopia
THEN surgery if required
flexible/rigid uteroscope is used to get stones from the kidney?
Flexible - so it can move into the calyces
Flexible/rigid uteroscope is used to get stones from the ureter?
Rigid
What is cystoscopy used for?
Follow up bladder cancer
Investigate ?bladder cancer
Name some LUTS
Voiding AND Storage
Voiding
- difficulty initiating
- poor stream
- post micturation dribble
Storage
- frequency
- urgency
- nocturia
Patient with white patches where foreskin usually contracts and bleeding. What is the likely diagnosis and management?
Diagnosis: balantitis xerotica obliterans
Management: Circumcision
BPH usually occurs in which zone of prostate?
Transitional zone (central)
Elderly male patient with LUTS. What examination do you do?
PR exam
Name 2 medications used to manage BPH (and their MOA)
Tamsulosin (alpha blocker - better flow)
Finasteride (5-alpha reductase inhibitor - shrinks prostate)
Which surgical procedure is carried out for BPH
TURP
Name 2 possible complications of BPH
Acute urinary retention
UTI
Name 2 risk factors for bladder cancer
Dye/chemical exposure, smoking
Painless frank haematuria. No other symptoms. What are you worried about?
Bladder cancer
In which region of the bladder does bladder cancer usually occur?
Trigone
Patient with painless haematuria. Which investigations do you want to carry out?
Urinalysis
Bloods
Flexible cystoscopy
CT urogram
Patient with painless haematuria. Flexible cystoscopy reveals an area which is potentially malignant. What do you do?
Rigid cystoscopy + biopsy
Management of bladder cancer (including follow up) in LOW risk patients
Transurethral bladder resection
Follow up with cystoscopy for ?3 years
Management of bladder cancer (including follow up) in HIGH risk patients
Transurethral bladder resection
Follow up with cystoscopy for 10 years
BCG injection
Which Vaccination helps reduce the recurrence of bladder cancer?
BCG
Management of bladder cancer if patient is not fit for surgery
external beam radiotherapy
Bladder cancer has a HIGH/LOW recurrence rate?
High
Which zone of prostate is it most common to get prostate cancer?
Peripheral zone
LUTS, haematospermia, weight loss, bone pain makes you think
Prostate cancer (advanced)
Suspect prostate cancer, which examination is done?
PR exam
- hard, craggy, irregular mass
Patient with ?prostate cancer, which investigations are valuable?
PSA
Trans rectal US guided prostate biopsy
PSA is a good diagnostic test. True or false?
False
- but it is good for monitoring
Scoring system used for prostate cancer (and breakdown)
Gleason score
- score < 6 - low risk
- score 6-7 - intermediate risk
- score 8-10 - high risk
Treatment of low risk prostate cancer
radical prostatectomy + radical radiotherapy
Treatment of intermediate risk prostate cancer
Radical prostatectomy + external beam radiotherapy + hormone therapy (LHRH agonist)
Penile cancer - common in young/elderly males?
Elderly
Elderly male with phimosis, raised red area of penis, red velvety patches on glans of penis. What is the likely diagnosis?
Penile cancer (SCC)
What is the investigation of choice for penile cancer
US
Testicular cancer - common in young/elderly male?
Young
What are the 2 broad categories of testicular tumours
Seminoma
Non-seminoma (yolk sac, teratoma)
Testicular tumour with solid homogenous pale macroscopic appearance
Seminoma
Which is more likely to spread: seminoma / non-seminoma?
Non-seminoma
Investigation of choice for ?testicular cancer?
US
Which tumour marker is raised in non-seminoma but NOT seminoma? PLAP B-HCG AFP LDH
AFP
Which tumour marker is raised in yolk sac tumours (non-seminoma) ? PLAP B-HCG AFP LDH
AFP
Which lymph nodes to testicular tumours typically spread to
Para aortic / aortocaval
Which is more RADIOsensitive: seminoma / non-seminoma
Seminoma
Which is more CHEMOsensitive: seminoma / non-seminoma
Non-seminoma
Define hydronephrosis
Back pressure of urine into the kidneys due to dilatation of ureters
- urine back pressure into the calyces compresses the nephrons within the medullary pyramids resulting in renal failure
Management of hydronephrosis?
Nephrostomy
Patient develops AKI after treatment of hypertension. What is the most likely diagnosis?
Renal artery stenosis
What is the management of acute urinary retention?
Catheterise
Foetus with small break in nose, low lying ears, regressing jaw. What is the likely diagnosis?
Potter’s syndrome
Name 5 causes of frank haematuria
Tumours (Bladder cancer, renal cell cancer, prostate cancer) Infection Stones Trauma Polycystic kidneys
What are the 2 best investigations to investigate frank haematuria
Flexible cystoscopy
CT urogram
Which medications (3) can look like patient is having haematuria
Nitrofurantoin
Anticoagulation
Rifampicin
Blood clots in urine
- long and worm like VS shapeless
Long and worm like - think upper urinary tract
shapeless - think lower urinary tract
What is the first line investigation if there is frank haematuria in over 50 year olds?
CT urogram
Best imaging Ix to look for stones
Plain CT scan
If you have a blocked nose you tend to have more problems in the lungs. True or false?
True
- nose is a protector of the respiratory tract so if blocked, more likely to have infections
What are the 2 top investigations for allergic rhinitis ?
RAST (specific IgE levels)
Skin prick testing
Which 2 immune things cause allergic rhinitis?
Histamine
Leukotrienes
Name 2 antihistamines used in the treatment of allergic rhinitis
Certirizine
Loratidine
Name 1 leukotriene receptor antagonist used in allergic rhinitis
Montelukast
Steroids are used in the treatment of allergic rhinitis. True or false?
True
- they are very effective
In which part of the cell do steroids work?
Nucleus
If a patient has an allergic rhinitis, GP has a look and refers to ENT because they see a ‘polyp’. What is is most likely to be?
Inferior turbinate, not a polyp
What is first line analgesia indicated for severe renal colic?
IM NSAIDs
FIrst line investigation of choice for patients presenting with suspected renal colic?
Non contrast CT KUB
28 y/o male presents with swelling within left scrotum., which aches when he stands. O/E: swelling is not tender and feels like a bag of worms. What is the likely diagnosis?
Varicocele
- more common in left
Painless scrotal swelling which transilluminates. Does this make your suspicion of testicular cancer increase or decrease?
Decrease
- more likely to be fluid (eg hydrocele or epididymal cyst)
Bladder US requires a full / empty bladder?
Full
- easier to assess outline
What is the gold standard investigation for local staging of bladder wall tumours?
MRI scan
Which investigation is good for detecting renal artery stenosis?
MR angiogram
Initial imaging of choice for ?prostate tancer
US
- Trans rectal US + biopsy
Imaging for staging of prostate cancer
MRI
What are the 3 anatomical sites of ureteric constriction (ie where are you most likely to get renal calculi)
Pelviureteric junction
Pelvic brim - Where ureter crosses over anterior aspect of common iliac artery
Ureteric orifice
Colicky loin -> groin pain Can't lie still Frank haematuria may have co-existing UTI What does this make you think of?
Renal colic
What is the investigation of choice for urinary tract calculi?
CT non contrast
- so this is safe in patients with renal impairment
Initial management of urinary tract calculi?
IM/IV diclofenac (NSAID) for analgesia
fluids
antibiotics if UTI present
Patient has a stone over 5mm with pain not resolving with analgesics. What do you do?
Tamsulosin
Nifedipine
These tablets promote expulsion
Management of patient with a large stone they are unable to pass using medical therapies / if stone not passed in 1 month (2)
Shockwave lithotripsy
Uteroscopy with basket
Severe suprapubic pain
O/E: distended, palpable bladder, dull to percussion
Acute urinary retention
2 options for management of upper urinary tract obstruction
Ureteric stent
Nephrostomy
Name 4 causes of acute urinary retention
Prostatic obstruction
Urethral stricture
infection
carcinoma
Immedicate management of acute urinary retention (2)
Suprapubic catheter Alpha blocker (tamsulosin)
Schistasomiasis inreases your risk of which type of tumour?
Bladder cancer - SCC
More likely to pass small volumes of urine in stress/urge incontinence ?
Stress - small
Young man wakes up in the middle of the night with extreme pain in one testis, N&V. O/E: testis is high in scrotum, very tender hot and swollen. What does this make you think of?
torsion of the spermatic cord
Which testicular pathology is an emergency
Torsion of the spermatic cord
Blue dot sign on mobile testis
Torsion of appendix testis
Which testicular problem is commonly associated with STI
Epidiymo orchitis
Varicocele usually affects left or right side
Left
Scrotum feels like a ‘bag of worms’. What does this suggest?
Varicocele
Diagnosis of torsion of spermatic cord is required before surgery. True or false?
False
- if suspected, urgent surgery required
A patient with primary open angle glaucoma is started on latanoprost eye drops to reduce her intraocular pressure. What is its main mode of action?
Increased aqueous absorption
Constriction of the pupil and opening the trabecular meshwork
Reduction in aqueous production at the ciliary body
Flattening of the lens by the ciliary muscle
Increased aqueous absorption
Which type of glaucoma medication causes growth of eyelashes
Prostaglandin analogues (latanoprost)
Which 2 classes of glaucoma medication reduce aqueous production at the ciliary body
Beta blocker (timolol) Carbonic anhydrase inhibitor (acetazolamide)
Which glaucoma medication causes constriction of the pupil and opening of the trabecular meshwork?
Pilocarpine
what is the most common sight threatening complication of branch retinal vein occulusion?
Macular oedema
A 70 year old woman is admitted headache and scalp tenderness and reports 1 stone in weight loss over the last 2 months. On examination, she has a non-pulsatile and tender super fical temporal artery on the right side. Bloods are taken which reveal a raised erythrocyte sedimentation rate (ESR). She has no signi ficant past medical history. What should be done next as a matter of priority? Temporal artery biopsy Arrange urgent CT Commence oral steroids Commence oral NSAIDs Commence IV NSAIDs
Commence oral steroids
- If ESR and CRP positive then given the clinical Hx it is most likely to be GCA.
- Confirmed GCA is treated with high dose oral steroids
- only where there is diagnostic uncertainty, temporal artery biopsy is required
In cataract surgery there is a corneal / scleral incision ?
Corneal
Name 2 complications of cataract surgery ?
Endophthalmitis
Unexpected refractive error
A young child is brought to the opticians with bilateral gritty red eyes. There is a watery discharge. He had recently been o ff school with a cold. On examination, he has some palpable lymphadenopathy in the preauricular area. What is the appropriate course of action?
- prescribe oral aciclovir
- prescribe topical chloramphenicol
- prescribe topical aciclovir
- cold compress / lubricants
- chloramphenicol ointment
Cold compress / lubricants
- this child has viral conjunctivitis
WHat drug is commonly used to treat viral herpetic keratitis?
Topical aciclovir
Sudden onset of ashes and oaters and a “curtain-like” shadow or veil across the vision are highly suggestive of
retinal detachment
A 87 year old man visits his GP with his daughter who has noticed he is increasingly bumping into things on his left side and has fallen at home on two occasions. His visual acuity is 6/9 in both eyes. On visual fi eld examination, he appears to be missing the temporal hemi field in the left eye and the nasal hemi field in the right eye. His pupils are reactive to light and accommodation and there is no RAPD. Where in the visual pathway is the problem likely to be located?
- right optic radiation
- left optic radiation
- optic chiasm
- right optic tract
- left optic tract
Right optic tract
What is the surgical treatmnt when medication fails in primary open angle glaucoma ?
Trabeculectomy
What is the treatment of low grade bladder cancer
Transurethral resection of bladder tumour (TURBT)
Local diathermy
What is the treatment of bladder cancer that has invaded into the detrusor muscle?
Radical cystectomy
Which is more likely to spread beyond testes: seminoma or non seminoma?
Non seminoma
Nasal polyps in children are common/uncommon
Uncommon
If you see child with nasal polyps think?
?Cystic fibrosis
What is more alarming: unilateral / bilateral polyps?
Unilateral
Most common location of epistaxis
Little’s area (anterior part of septum)
Name 4 potential causes of epistaxis
Trauma
Tumour
Anticoagulants
Bleeding disorders
Treatment of epistaxis (3 options)
- External digital compression / pressure
- Cautery (with silver nitrate)
- Nasal packing
Treatment of chronic sinusitis?
Surgical enlargement of sinus drainage opening when maximal medical therapy (antibiotics / nasal vasoconstrictors) has failed
How to classify rhinitis
Infective - viral usually (rhinosinusitis) Non-infective - allergic - non-allergic (polyps)
What are the most common allergens of allergic rhinitis
Grass and tree pollen
How to classify intermittent vs persistent rhinitis?
Intermittent = less than 4 days per week or less than 4 weeks
Persistent = more than 4 days per week AND more than 4 weeks
Name 2 investigations for allergic rhinitis
Skin prick testing
RAST
Medical management of nasal polyps
topical +/- oral steroids
What is the most common bacterial cause of sore throat?
Streptococcus pyogenes (group A strep)
Name 4 potential complications that can occur with bacterial sore throat?
Peritonsilar abscess (quinsy)
Rheumatic fever
Glomerulonephritis
Severe sore throat with grey-white membrane across the pharynx
Diphtheria
Which virus causes infectious mononucleosis?
EBV
Sore throat, fever, enlarged cervical lymph nodes, malaise, lethargy, rash. On examination white exudate coats tonsils. What does this make you think
Infectious mononucleosis
Investigations for infectious mononucleosis
Bloods - atypical lymphocytes (B lymphocytes) - low CRP (surprising) EBV IgM - Monospot test - Paul Bunnel test Maybe have raised LFT
Management of infectious mononucleosis
Self limiting
If severe, oral corticosteroids
What happens if you give a patient with sore throat antibiotics? (presumed to be bacterial but its actually infecious mononucleosis)
Generalised macular rash
Chromafin positive gangliomas are usually above/below the diaphragm and produce ____?
Below
Produce adrenaline
Which is more likely to present with lymphadenopathy: viral or bacterial tonsilitis?
Bacterial
Throat swab is recommended in tonsilitis. True or false?
False
- core species do not always correlate with commensal surface bacteria
Which antibiotic is used to treat bacterial tonsilitis?
Phenoxymethylpenicillin
Surgery (tonsilectomy) is only considered if patient has X or more episodes of tonsilitis per year?
7 or more
Criteria used to differentiate between bacterial and viral sore throat
CENTOR criteria
- absence of cough
- tonsilar Exudates
- tender cervical lymphadenopathy
- temperature
- age under 15 - add 1 point
- age over 44 - subtract 1 point
CENTOR criteria score 0-1 management
Self limiting, viral cause
CENTOR criteria 2-3 management
Antibiotics if symptoms persist, possible bacterial infection
CENTOR criteria 4-5 management
Treat empirically with antibiotis
Hx of preceding tonsilitis then unilateral throat pain, odynophagia, lock jaw
Peritonsilar abscess
What is the management of a peritonsilar abscess
Aspiration
What is the most common cause of noisy breathing in infancy?
Laryngomalacia
What are the 2 types of benign HPV
6 and 11
What are the 2 types of malignanct HPV
16 and 18
What condition causes subglottic stenosis ?
Small vessel vasculitis
Cancer of the vocal cords is very likely / unlikely to metastasise?
Very unlikely
Supra glottis tumours spread to which lymph nodes
Deep cervical lymph nodes
Infra glottis tumours spread to which lymph nodes
Paratracheal lymph nodes
Salivary gland tumours - which gland is most often affected?
Parotid gland
Where does a pleomorphic adenoma commonly occur?
Parotid gland
Name 4 risk factors for head and neck cancer
Smoking (elderly)
Alcohol (elderly)
Viruses (HPV and EBV) - younger onset
Betel nut chewing
Red flag symptoms suggestive of throat cancer
Persisting sore throat Hoarse voice Change in voice (recurrent laryngeal nerve) Stridor Dysphagia Odynophagia Neck lump
Head and neck cancer: small tumour, big lymph nodes
HPV
What is the first line investigation in suspicious neck mass?
US + FNA
Examining cervical lymph nodes
Zig zag
- medial to lateral using finger prints
- down anterior triangle using pincer grip
- along clavicle area using flat hands
- pre auricular, post auricular
- occipital
39 year old overweight female with soft supraclavicular swelling. US normal, bloods normal. What is the likley diagnosis?
Supraclavicular fat pad
Neck swelling + dilated veins
?SVC obstruction
Swollen lymph glands + young patient …
Think ?lymphoma
2 common locations for HPV cancer
Base of tongue
Tonsils
Treatment of non severe nasal polyps
Topical steroids
Treatment of severe nasal polyps
Oral steroids
What is a pleomorphic adenoma?
Benign salivary gland tumour
Which salivary gland is most affected by tumour (benign or malignant) ?
Parotid gland
Which muscle is good for distinguishing between anterior and posterior triangle of neck?
Sternocleidomastoid
B-symptoms (?lymphoma) in neck lump
Night sweats
Weight loss
When feeling for neck lump what should you report (4)
Where is it located
Is there only one lump?
Is it mobile or fixed?
What imaging investigation is good for staging head and neck cancer
CT scan
What imaging investigation is good for salivary glands
MRI sca n
Rule of 80’s for cervical lymph nodes
80% cancerous
80% metastasis, only 20% lymphoid (ie lymphoma)
80% of primary sites are above level of clavicle
Rule of 80’s for salivary gland tumour
80% parotid gland
80% benign
80% pleomorphic adenoma
Name 2 benign salivary gland tumours?
Pleomorphic adenoma
Warthins tumour
Features of malignant salivary gland tumour
Facial nerve palsy
Pain
Lymphadenopathy
Thyroid lumps move on swallowing. True or false?
True
2 most important things to ask in thyroid pathology Hx?
Hx of radiation exposure
FHx thyroid cancer
Thyroid cyst - what are the TFTs like
Normal
Investigation of thyroid cyst
US
CT scan
Multinodular goitre investigation
US - benign
Multinodular goitre TFTs
Normal
Hashimotos thyroiditis TFTs
Hypothyroid (T3/T4 low, TSH high)
TPO elevated
Graves disease TFTs
Hyperthyroid (T3/T4 high, TSH low)
Most common type of thyroid cancer
Papillary
Rapid onset neck mass, midline, airway issues and hoarseness. Which type of cancer is this
Anaplastic
Mainstay of management for thyroid papillary cancer
Surgery and radioactive iodine
Most common cause of lymph nodes in children?
Reactive lymphadenopathy (infectious cause)
Congenital neck lumps: dermoid
- location
- treatment
location: midline, can have a hair in it
Treatment: surgery
Congenital neck lumps: thyroglossal cyst
- location
Location: midline, moves on swallowing, over larynx and below hyoid usually
Congenital neck lumps: cystic hygroma
- location
- treatment
Location: posterior triangle
Treatment: surgery or sclerotherapy
Branchial cyst location
Anterior triangle
Cystic hygroma is common in elderly / young?
Young - present at birth
Name top 3 head and neck malignancies in children?
Lymphoma
Rhabdomyosarcoma
Neuroblastoma
MEN is associated with which type of thyroid cancer?
medullary
Which type of thyroid cancer is most common in children?
Medullary
A patient will be diagnosed to have recurrent Urinary tract infections (UTIs), if the frequency of UTIs episode is at least:
3 in one year
or
twice in 6 months
Which 1 of the following findings on urine dipstick would suggest a patient is likely to have UTI?
- presence of leukocytes
- presence of nitrites
- presence of blood
- pH >7.5
Presence of nitrites
Name 3 classes of antibiotics effective in the treatment of prostatitis?
Ciprofloxacin
Doxycycline
Co-trimoxazole
Young patient, age 30, with multiple recurrent UTIs. US urinary tract shows no abnormalities. What is the next best investigation?
- CT urogram
- CT stone search
- flexible cystoscopy
- KUB X-ray
FLexible cystoscopy
? bladder cancer. Flexible cystoscopy done and did not show any abnormality. What is next investigation?
- CT urogram
- Urine culture and sensitivities
- US urinary tract
- PSA level
CT urogram
Staghorn calculi are associated with what types of urinary stone?
magnesium ammonium phosphate stone
Proteus?
A male patient is admitted with history of left ureteric colic. CT stone search showed, radiolucent 5 mm left distal ureteric stone. His observations are stable and afebrile but pain is persisting and blood tests showed worsening renal function.
What is next step in management and WHY?
- ureteric stent insertion
- ESWL (lithroplasty)
Ureteric stent insertion
- over 5mm in size so must be removed
- worsening renal function
When do you use ureteric stent insertion over ESWL for ureteric stone removal
If infection or obstruction present, use stent insertion
A 60-year-old diabetic male, has bothersome mild to moderate lower urinary tract symptoms, along with erectile dysfunction.
Which of following medications will be the best choice to alleviate his symptoms?
- phosphodiesterase-5 inhibitors (tadalafil)
- 5-alpha reductase inhibitor (finasteride)
- alpha blocker (tamsulosin)
- muscarinic receptor inhibitor (tolteridine)
phosphodiesterase-5 inhibitors (tadalafil)
patient with sudden visual blurring bilaterally and light sensitivity. BP 191/127. On dilated fundoscopy both optic discs re swollen, cotton wool spots and flame haemorhages. What is likely diagnosis and what is first line Tx?
Hypertensive retinopathy
IV labetolol
Only way air can get into the middle ear is through
Eustachian tube
What is Jacobson’s nerve
Branch of CN IX
What is Arnold’s nerve
Branch of CN X
Name 5 areas that the CN V3 supplies
Anterior 2/3rd of tongue Inferior oral cavity Floor of mouth Lower teeth Salivary glands
What supplies posterior 1/3rd tongue
CN IX
Otalgia + hearing loss makes you think
?obstruction
Otalgia + tinnitus or vertigo? where is the problem likely to be?
In the inner ear
TMJ problems tend to affect women/men ?
Women
Which is a red flag in ENT: unilateral or bilateral neck mass?
Unilateral
Patient with otalgia + unusual looking tonsil ?malignancy what imaging investigation is done?
CT scan
Management of CN IX neuralgia
- unilateral tingling / throbbing type of pain ?
Carbamazepine
Gabapentin
Amitryptiline
What is necrotising otitis externa?
What is the common causative organism?
What is the treatment?
When otitis externa extends into the temporal bone
Pseudomonas aerguinosa
Hospitalisation for 6 weeks IV antibiotics
Patient with chronic earache
- normal ENT exam
- normal dental exam
What do you do?
MRI
Which 2 things to do when examining TMJ
- look at patient straight on and assess symmetry
2. feel TMJ for crepitus whilst patient opens and shuts mouth
Which nerves can cause referred otalgia (4)
C2 and C3
CN V3
CN IX
CN X
How can C2 and C3 spinal nerves cause otalgia?
Through arthritis / cervical spondylosis
Name 3 ways which CN V3 can cause otalgia (3)
Dental disease (eg tooth impaction, abscess) TMJ dysfunction Nasopharyngeal disease
Name 2 ways which CN IX can cause otalgia
tongue base tumor
Almost any oropharyngeal infective process (tonsilitis, pharyngitis, quinsy)
Name 1 way in which CN X can cause otalgia ?
Malignancy or larync and hypopharynx
Stertor is caused by obstruction of airway above/below the larynx?
Above
Low pitched snoring or snuffly sound
Stertor
In which condition do you get stertor
Obstructive sleep apnoea
Stridor is due to air flow changes within the larnynx, trachea or main bronchi. True or false?
True
Continuous noise, whistling in nature
Wheeze
Wheeze is common by conditions affecting upper/lower respiratory tract?
Lower
What does normal voice production require
Vocal cords need to come together, dring the closure they vibrate
laryngectomy vs tracheostomy
laryngectomy - complete removal of the larynx, trachea brought to the skin as a stoma, person can only breathe through stoma
tracheostomy - hole made in the trachea, person can breathe through nose and mouth
Speech through speaking valve can be done in laryngectomy / tracheostomy?
Tracheostomy
Airway emergency (eg stridor) management
OXYGEN
Heliox (helium and oxygen)
nebulised adrenaline
How to secure an airway obstruction - get in above/below cause of obstrution?
Below
3 options for securing an airway if patient has an airway obstruction
Intubation
Cricothyroidotomy
Tracheostomy
When may you use a nasopharyngeal airway instead of oropharyngeal airway?
Severe anaphylaxis so tongue is swollen and there is no way of getting tube down the mouth
Severe fractures of the jaw so can’t open mouth
Cricothyroidotomy is usually temporary measure / permentent?
Temporary measure
What is used to treat cancer of the larynx? tracheostomy / laryngectomy?
Laryngectomy
Causes of nose bleeds
Trauma Tumour Medication - warfarin Patient's with low platelets GPA HHT - hereditary haemorrhagic telangectasia
Pubertal boy with recurrent epistaxis
juvenile nasal angiofibroma
Which autoimmune condition causes epistaxis
GPA
Name 2 principle parts of the body that GPA affects
Renal
Lungs
If GPA in the nose is not treated, what happens to the nose?
Saddle deformity
nasal septum gone.
First line management of epistaxis in any situation
Apply external compression
Lean forward - so that you don’t swallow the blood
Suck on ice
Treating of epistaxis in A+E
Adrenaline + lidocane gauze up nose to stop bleeding (constricts vessels and numbs nose) + tranexamic acid
then cauterisation
Then packs
85 y/o patient with epistaxis, tried everything including packing but nothing helping. Not fit to go under GA. What do you do?
Interventional radiology - embolize
Unmasked bone conduction,
Hear it in the ear that hears best
Sensorineural hearing loss at high frequency
Presbycusis
4K dip on audiogram, sensorineural, what is the likely cause
Noise exposure
low frequency sensorineural hearing loss is classically what you get in which condition?
Menieres disease
How can you tell if you’re looking at T1 or T2 MRI
Fat is bright on T1 and T2, bone is black on T1 and T2
Water is bright in T2
Water is dark in T1
Unilateral sensorineural hearing loss, What do you do?
MRI scan to check for vestibular schwanoma
Name 6 treament options (in order) for epistaxis
- external compression + ice
- Cauterisation with silver nitrate
- Nasal packing
- Endoscopic ligation of sphenopalatine artery
- ligation of the external carotid artery
- embolisation
Name the 5 vessels which supply the nasal cavity
Greater palatine artery Sphenopalatine artery Anterior ethmoidal artery Posterior ethmoidal artery Superior labial branch of the facial artery
The sphenopalatine artery mainly supplies which area of the nose?
Lateral wall
Antihistamines used in allergy are more specifically antagonists of which histamine receptors? H1/H2/H3/H4
H1
Which symptoms might be caused by chronic ottitis media with effusion?
- recurrent otalgia
- recurrent ear discharge
- hearing loss
- none
- all of the above
All of the above
What would tympanic membrane look like in chronic ottitis media with effusion?
- name 2 features
Retracted and dull
HPV head and neck cancer usually responds well/poorly to treatment?
Well
Patient with vertigo episodes - last up to 4 hours - preceding aural fullness - tinnitus what is likely diagnosis?
Meniere’s disease
Which 2 of the following features make quinsy more likely than tonsilitis
- voice change
- history of previous tonsilitis
- change in sense of taste
- loss of appetite
- headache
- laterality of sore throat
Laterality of sore throat
Voice change
Which feature in the full blood count might be helpful in demonstrating infectious mononucleosis? Microcytic anaemia Neutropenia Lymphocytosis Thrombocytopenia Neutrophilia
Lymphocytosis
Sudden unilateral hearing loss (sensorineural) then vertigo later. What is likely?
Vestibular schwannoma
Prolonged vertigo for a number of days (can last for 3 weeks)
Patient may feel nauseous and vomit
No associated tinnitus
No associated hearing loss
Vestibular neuronitis
What investigation do you do to confirm if a patient has middle ear effusion? and what will it show?
Tympanogram - flat line
What is the main complication to be aware of of acute otitis media?
Acute mastoiditis
gradual onset conductive hearing loss with normal examination findings
Otosclerosis
Which treatment is contraindicated in patients with otosclerosis?
HRT
B cells / T cells produce IgE ?
B cells
Name 2 things which mast cells produce
Histamine
Leukotrienes
Patient presents to GP with nose blockage. Fixed and always present in Right side. Name 2 possibilities
Septal deviation
Nasal polyps in right
Patient with allergic rhinitis in GP. How long should they be treated for and what are examples of treatment
Treat for 3 months
Avoidance of trigger
Anti-histamines - certirazine, loratidine
Topical steroids - fluticasone, beclometasone
LTRA
Patient with hoarseness should be referred from GP -> secondary care if the hoarseness persists beyond ???
3 weeks
Patient with the following symptoms - persistent dysphonia - stridor / airway obstruction - dysphagia - otalgia - neck nodes What is likely diagnosis?
Laryngeal cancer
Majority of people with laryngeal cancer will need a laryngectomy. True or false?
False
- most treated with radiotherapy / chemoradiotherapy / laser surgery
Cricoid cartilage is above/below thyroid cartilage
Below
All laryngeal muscles are supplied by which nerve?
Apart from which muscle?
All laryngeal muscles are supplied by RLN apart from cricothyroid muscle.
What would happen if the patient had a bilateral vocal cord palsy ? What would they need?
Wouldn’t be able to speak or difficulty swallowing
- needs tracheotomy
Which nerve is involved in vocal cord paralysis?
Vagus nerve
What is the most common cause of renkie’s oedema?
Smoking
Which nerve supplies the middle ear?
And what specifically is it called?
CN IX
Jacob’s nerve
Management of TMJ dysfunction
NSAIDs
Soft diet
Dental guard
Refer to dentist
What is hairy leukoplakia associated with?
EBV
? suspicious lesion in salivary gland. What is best investigation? CT or MRI?
MRI
Causes of congenital sensorineural hearing loss non-genetic (2)
Maternal infection
Alcohol/drug misuse during pregnancy
Causes of acquired sensorineural hearing loss (7)
Presbyacusis (age related)
Noise induced
Inflammatory (meningitis, mumps, measles, syphilis)
Autoimmune (GPA, sarcoidosis, rheumatoid arthritis)
Vestibular schwannoma
Meniere’s disease
Ototoxic drugs
Rapidly progressing, fluctuating, unilateral sensorineural hearing loss. What is likely cause and how would you treat
Autoimmune
- GPA / sarcoidosis / rheumatoid arthritis
- Tx: steroids +/- immunosuppression
Patients presenting with unilateral sensorineural hearing loss should have what investigation and why
MRI
Check for vestibular schwannoma
menieres disease is typically low/high frequency hearing loss
Low
Name 2 drugs which are ototoxic
Gentamicin
Platinum based chemotherapy agents
Newborn undergoes hearing assessment on the ward and fails. What is next step?
Re-test
Newborn undergoes hearing assessment and fails, then fails the re-test. What is next step?
Brainstem evoked response audiometry
Sensorineural hearing loss present at birth / develops in childhood
Retinitis pigmentosa (gradual onset visual impairment)
balance problems
Autosomal recessive
Usher’s syndrome
Sensorineural hearing loss presetn at birth
Different coloured iris
White patch of hair
What is this syndrome called and what is mode of inheritance?
Waardenburg’s syndrome
Autosomal Dominant
Sensorineural hearing loss
Goitre (with normal or reduced thyroid function)
What is the syndrome and what is mode of inheritance?
Pendred’s syndrome
Autosomal recessive
Where in the nose are nasal packs inserted in epistaxis?
Along the hard palate
Patient has ongoing epistaxis despite first aid cauterisation and nasal packing, what is the most common operation?
Sphenopalatine artery ligation
Patient has ongoing epistaxis despite first aid cauterisation and nasal packing, what is the last line operation?
Embolisation with IR
Whats the treatment of Bell’s palsy
Early high dose steroids
What is ramsay hunt syndrome
Shingles affecting the facial nerve
Parotid swelling + facial nerve palsy suggests
Parotid malignancy
Which systemic disease can cause a facial palsy
Lymes disease
What is the treatment of ramsay hunt syndrome
Oral steroids (5 days) + oral antiviral (aciclovir - 7 days)
Name 3 complications of obstructive sleep apnoea
Pulmonary hypertension
- cor pulmonale
- cardiac dysrhythmias
Daytime solemnence
OSA and DVLA
Must tell DVLA you have OSA
OSA and DVLA and HGV
Can’t drive HGV until OSA treated
Management of OSA in children
Adenotonsillectomy
Hypermetropia is a risk factor for open/closed angle glaucoma?
Closed angle
Visual field defect in the macula will be
Central scotoma
Which of the following fundoscopy findings is a key feature of grade 4 hypertensive retinopathy?
- AV nipping
- cotton wool spots
- papilloedema
- flame haemorrhages
Pappiloedema
Myopia is a risk factor for which condition?
Retinal detachment
26 year old seeks medical attention for red eye. He wears contact lenses, and apart from redness is entirely asymptomatic. What is likely cause?
Episcleritis
Risks for subconjunctival haemorrahge
Straining
- cough
- sneeze
Treatment of choice for CMV retinitis
Gancyclovir
Temporal lobe lesions cause a homonymous SUPERIOR/INFERIOR quadrantopia
Superior
- PITS
AV nipping is an early/late change seen in hypertensive retinopathy
Early
Branchial cydt
Cystic hygroma
Which is more common in children?
Cystic hygroma
What is the investigation of choice for acoustic neuroma?
MRI scan
Patient over 45 with visible haematuria that persists or recurs following UTI. What should you suspect?
Bladder cancer
Patient with BPH and urinary retention. Has TWOC but fails. What should you do?
TURP procedure
What does the lingual nerve supply?
Taste for the anterior 2/3rds of the tongue
What is the treatment of ottitis externa?
Topical antibiotics +/- steroids 7 days
