MSK, EYES Flashcards
EAR NOSE THROAT
Learning objectives for lecture
What typanometry -used if otoscope +insufflator
Holding otoscope like pen-
How And straighten canal
Know how to use otoscope and insufflator
What are landmarks of the ear drum>=?
What
Case 1
Ask antenatal history, Paeds hx, immunisation, social history
Note
ANswer to management
Case 2
WHat is the management of otitis externa
ICS, antibiotic, anti-fungal
Keep ear dry
Dry aural toilet
Prevent ear dry for 2 weeks post diagnosis
Examination:
CASE 3 diagnosis and management
Always consider UTI in little girls
Note in little girls hard to localise pain
Case 4
Tonsillitis
Bilateral anterior lymph node
Viral
Bacterial
EBV
Viral, bacterial, EBV
What is the modified Centro criteria?
What is a quinsy?
What is the management of of a sore throat
What is a quinsy
tonsil abscess
What are Post strep complications
CASE 5.
What are you differentials?
Unilateral red eye-
Uvetits, conjunctivitis, stye, iritis, visual acuity, character. Ask about visual loss, discharge
What further history will help you make a definitive outcome
Answer to unilateral red eye causes
Know DDX
Know Management of each
Do a swab of the eye discharge- bacteria for culture
question? How would you examine this patient?
Look - At eye
Visual acuity
Inspection
Face orbit, cervical lymp
Hypoponoma - Front to back- white in the eye is ad
Unilateral red eye exclude the serious
What is the management of acute angle closure glaucoma
What are the 5 key features of Glaucoma?
What is microbial keratitis ? What are they causes? What is the management
What is Iritis? What are the association
What is herpes Zoster opthalmicus
Severe pain before - papule appear
What are the three divisions of facial nerve
Management
What is a dendritic ulcer?
Ulcer HSV
What is ocular herpes simplex
What are the red flags for eye examination
Case study: A painful red eye - Case study RACGP
A man, 75 years of age, presents with a red, painful, watery right eye of 1 week duration. He describes photophobia but says his vision is not reduced or blurry. He was seen at another clinic after 2 days of symptoms and was prescribed topical chloramphenicol
antibiotic eye drops. Despite using the eye drops for 5 days,
there has been no improvement in his symptoms. The man has no
significant ocular past history.
Question 1- What are your differential diagnoses and what further history will help you to make a definitive diagnosis? - Hinted exam qs
Question 2 -How would you examine this patient?
Question 3- What is the most likely diagnosis (Figure 1)? How is this condition
managed?
Question 4- What are the potential ocular complications of this condition?
Question 5- What lessons can be learnt from this case?
A focused history can help make a definitive diagnosis.
Important questions to ask in the history are shown in Table 2.
Conjunctivitis accounts for over 25% of all eye complaints seen
in the general practice setting, and can be allergic, viral or bacterial.1
Allergic conjunctivitis is usually bilateral and accompanied by itch
and a history of atopy. Viral conjunctivitis is characterised by a watery
discharge and may be associated with a history of viral illness. A
purulent discharge is usually present in bacterial conjunctivitis.
A corneal foreign body can cause irritation and redness; it is
important to seek a history of any ocular trauma or work with metal.
If the patient is a contact lens wearer, microbial keratitis with
organisms such as Pseudomonas aeruginosa or acanthamoeba, must
be considered. This condition can lead to devastating outcomes
including corneal perforation. As a rule, a contact lens wearer with a
painful, red eye should be referred for prompt specialist assessment.
Anterior uveitis can present with redness, photophobia, pain and
blurred vision. Acute angle closure glaucoma (also known as acute
glaucoma) causes severe pain, photophobia and visual impairment.
There is often associated nausea and vomiting.
Question 2-
How would you examine this patient?
- An eye examination should be performed on every patient presenting with an eye complaint . The only equipment required for a basic examination is a Snellen chart, an ophthalmoscope, and 1% fluorescein dye.
- First, inspect the eyes for distribution of redness, obvious corneal foreign bodies and eyelid swelling/redness. Evert both lids to check for subtarsal foreign bodies. Pre-auricular nodes should be palpated as viral conjunctivitis is often associated with preauricular lymphadenopathy.
- In acute angle closure glaucoma, the pupil may be fixed and mid-dilated, and the cornea may appear cloudy due to oedema.
- Anterior uveitis tends to be difficult to diagnose without a slit lamp examination; the characteristic slit lamp appearance is of inflammatory cells in the anterior chamber, with circumcorneal injection of blood vessels. However, if adhesion bands form between the iris and anterior lens capsule (posterior synechiae), a small and irregular pupil may be seen on basic eye examination.
- Visual acuity should be checked in each eye separately, withthe patient wearing their usual glasses and using a Snellen chart at a distance of 6 metres. A pinhole is useful to minimise the effect of refractive error if the patient has not brought their glasses. The pupils should be checked for both direct and consensual responses.
- The swinging flashlight test will detect a relative afferent pupillary defect (Marcus-Gunn pupil).
- The cornea should be examined for abrasions or ulcers using 1% fluorescein drops illuminated with a cobalt blue light (a feature available on most direct ophthalmoscopes) in a darkened room.
- Local anaesthetic drops (eg. amethocaine) can aid in the examination, but should never be prescribed for the patient to use at home.
Question 2-
How would you examine this patient? Continued (examination image)
Question 3- What is the most likely diagnosis (Figure 1)?
How is this condition
managed?
Answer 3:
- This is a dendritic ulcer, the characteristic lesion of herpes simplex virus (HSV) keratitis.
- The typical branching dendritic shape is clearly demonstrated.
- The base of the ulcer stains with fluorescein as a result of impaired cellular integrity and intercellular tight junctions.
- Herpes simplex virus keratitis is potentially sight threatening, and should always be considered in the differential diagnosis of a unilateral red eye.
- A viral eye swab may be sent for polymerase chain reaction for herpes simplex virus DNA.
- Initial management is with topical acyclovir eye ointment administered five times daily.
- The patient should be promptly referred to a specialist to confirm the diagnosis and assess for complications.
- It is important to note that topical steroids can cause disastrous complications in cases of herpes simplex infection.
- As a general rule, an initial prescription for topical ocular steroids should only be written by an ophthalmologist after a comprehensive ocular examination to exclude conditions that can worsened with steroid use.
What are important Questions on history and examination with any unilateral red eye? Think why
Question 5:
AOM- RCH guidelines - Presentation, prevalance? causes? assessment? Management?
Key Points
- Do not accept otitis media as the sole diagnosis in a sick febrile young child without exclusion of more serious causes (see Febrile child)
- Diagnosis requires acute onset and an abnormal ear examination with signs of middle ear inflammation and middle ear effusion
- Avoid the routine use of antibiotic treatment for acute otitis media
Background
- Acute Otitis Media (AOM) is a common problem in early childhood
- 75% of children have at least one episode by school age
- Peak age prevalence is 6-18 months
Causes of acute otitis media are often multifactorial. Exposure to cigarette smoke from household contacts is a known modifiable risk factor
Assessment
History
- Recent onset ear pain (irritability in pre-verbal children)
- Fever
- Loss of appetite
- Vomiting
- Lethargy
- Cochlear implant
- Immunocompromise
Examination
- Otoscopic Images of Tympanic Membranes (TM):
Normal Tympanic Membrane
- TM is translucent
- The handle of the malleus is vertical
- No erythema
Injected Tympanic Membrane
- Pink/red TM
- Often seen with fever, eustachian tube obstruction or viral URTI
- TM is transparent (there is no middle ear effusion)
- The handle of the malleus is well seen and is more horizontal
Bulging and red tympanic membrane in AOM
- Loss of the TM landmarks, especially the handle of the malleus
- TM is opaque, may be red from inflammation or white from pus in the middle ear
Otitis Media with Effusion (OME) “glue ear”
- TM is retracted with prominence of the handle of the malleus, which is also drawn in/more horizontal
- TM may be bulging or have an air-fluid level behind the TM
- Yellow/amber appearance is consistent with fluid
- Light reflex on otoscopic examination
Perforated Tympanic Membrane with otorrhoea
Otitis Externa
- Ear is tender to examine
- Skin of the external ear canal is swollen and there can be thin pus
Management
- In Infants, especially <6 months old, the diagnosis of AOM and OME can be inaccurate. Other diagnoses should be fully considered (see Febrile child)
- Management may also differ for children from higher risk groups, such as those living in Aboriginal or Torres Strait Islander communities (see additional resources below)
Investigations
Management
In Infants, especially <6 months old, the diagnosis of AOM and OME can be inaccurate. Other diagnoses should be fully considered (see Febrile child)
Investigations
- There is no role for routine diagnostic investigation for AOM
- Diagnostic imaging such as CT and MRI is usually only required in children with suspected intracranial complications
Treatment
What is the treatment and complications of AOM? etc
Acute Mastoiditis (AM)
- Acute mastoiditis, although rare, is the most common suppurative complication of AOM and may be associated with intracranial complication
Tympanic membrane perforation
Acute Mastoiditis (AM) Acute mastoiditis, although rare, is the most common suppurative complication of AOM and may be associated with intracranial complications
- AOM with TM perforation is common and results in otorrhoea and frequently, relief of pain
- Otorrhoea due to TM perforation should be distinguished from Otitis Externa
- The diagnosis of AM is based on post auricular inflammatory signs (erythema, oedema, tenderness or fluctuance), a protruding auricle often with external auditory canal oedema and signs of AOM (see image below)
- Requires prompt treatment with appropriate intravenous antibiotics (eg flucloxacillin plus 3rd generation cephalosporin)
Consult ENT as may require surgical treatment
Other complications
- Otitis Media with Effusion (OME)
Consider consultation with local paediatric team when
- Children requiring care beyond the level of comfort of the local hospital
- The diagnosis of AM is based on post auricular inflammatory signs (erythema, oedema, tenderness or fluctuance), a protruding auricle often with external auditory canal oedema and signs of AOM (see image below)
- Requires prompt treatment with appropriate intravenous antibiotics (eg flucloxacillin plus 3rd generation cephalosporin)
- Consult ENT as may require surgical treatment
Other suppurative complications including intracranial spread of infection are rare
- Facial nerve palsy secondary to AOM should be discussed with ENT
- Long-term non suppurative complications include atelectasis of the TM and cholesteatoma
- OME, previously termed serous otitis or glue ear, is fluid in the middle ear without signs and symptoms of infection, other than transient hearing impairment
The presence of a middle ear effusion is not a diagnostic sign of AOM (an effusion may not resolve for up to 12 weeks following AOM)
- Antibiotics and ENT referral are not routinely required for OME, as the majority of cases occur after an episode of AOM and resolve spontaneously with no long-term effects on language, literacy or cognitive development
- Persistent effusion beyond 3 months should trigger a hearing assessment and ENT involvement/referral
Consider transfer when
- Children who are systemically unwell
- Neonates
- Children with signs of acute mastoiditis or who have a cochlear implant should be discussed with ENT
