ent/ophth Flashcards
(58 cards)
1
Q
which eyelid tumour is very responsive to radiotherapy
A
kaposi’s sarcoma
2
Q
what are the top 3 managment of eyelid tumours
A
- surgical excision (first line, for SCC, BCC and melanomas)
- radiotherapy (for SCC, BCC and Kaposi’s)
- Cryotherapy
3
Q
what are the different types of eyelid tumours
A
- SCC
- BCC
- melanomas
- meibomian gland carcinoma
- kaposi’s
- merkel cell carcinoma
4
Q
what is kaposi’s sarcoma associated with
A
HIV/AIDs paitent, vascular tumour
sensitive to radiotherapy
5
Q
which eyelid tumours have a predilection for upper eyelid
A
merkel cell carcinoma
meibomian gland carcinoma
6
Q
which eyelid tumours have predilection for lower eyelid
A
SCC
BCC
7
Q
write short notes on conjunctival SCC
A
- the most common malignancy of conjunctiva
- risk factors include chronic sun exposure, immunosuppresion
- presenting as red eye, pain, watering, burning sensation and decreased vision.
- tx with surgical excision, cyrotherapy, +/- adjuvant therapies such as radiotherapy and topical chrmotherapy agents.
8
Q
write short notes on choroidal melanoma
A
- most common primary malignancy of the posterior uvea (choroid and ciliary body)
- most common primary intraocular tumour in adults
- presenting with collar-stud or dome shaped lesions
- patients can present with retinal detachment or lipofuscin deposition
- treatment determined based on multifactors, but include brachytherapy, localresection, enucleartion, laser treatment, rarely observation
9
Q
creamy, yellow, subretinal deposits that grow rapidly
A
ocular metastasis
tx includes controlling the primary tumour site, local treatment to the eye with external beam radiothearpy or photodynamic thearpy to preseve as much vision as possible
- commonest primary sites are lung (m) and breast (f)
10
Q
write short ntoes on reinoblastomaw
A
- most common primary intraocular malignancy in children
- can be unilateral or bilateral (U/L in 2/3, B/L in 1/3)
- can be sporadic (60%, need 2 mutations in somatic cells, unifocal and unilateral) or inherited (40% need 1 mutation in germ line cells, multifocal bilateral presentation)
- presents before 3y, mean diagnosis age is 18months
- presentation: LEUKOCORIA, but can also present as squint, orbital cellulitis and increased IOP
- can be endophytic (growing into the vitreous) or exophytic (growing under the retina)
- tx - good prognosis, one of the best cure rate
**pathophysio: Rb1 gene involved is a tumour suppressor gene
11
Q
what are the most common primary intraocular malignancies in children and adults respectively?
A
children: retinoblastoma
adults: choroidal melanoma
12
Q
what are the presentations of orbital blow out fractures
A
floor:
- periocular ecchymosis, oedema
- infraorbital anaesthesia
- ophthalmoplegia (double vertical diplopia)
- enophthalmos (posterior displacmetn of eye)
medial wall:
- periocular subcutaneous emphysema (connected medial wall to the ethmoid, gets worse with nose-blowing)
- ophthalmoplegia (horizontal diplopia)
13
Q
how to treat blow out fractures / orbital tissue entracpement
A
can cause diplopia, limited eye movements
- coronal CT scan
- release the entrapped tissue via surgery
- repair the bony defect
14
Q
which type of chemical injury is more destructive to the eye
A
alkali, as it can penetrate into the deep layers with time
in high concentrations can cause severe ischaemia of conjunctiva, corneal limbus, cornea and sclera
associated with severe uvieitis and cataract ormation
15
Q
how to manage a paitent with suspected chemical injury
A
- wash out the eye
- measure the eye pH if possible
- if not apply topical anaesthetic drops immediately
- Irrigation (MOST IMPT) ++++++ in a copious amount, with normal saline / Ringer’s solution / normal cold tap water for 15-30 minutes to restore the pH, then repeat the pH measurement
- ensure that the surface of eye, upper and lower fornices are included, use cotton bud to evert the upper lid, remove anything.
- measure VA, check IOP
- admit
- topical tx
- intensive topical antibiotics (topical and systemic tetracycline)
- topical steroids to reduce inflammation
- cycloplegia to remove the pain
- treat raised IOP as requried - oral high dose vitamin C (anti-oxidant)
- laser surgery if required
16
Q
what is papilloedema
A
swelling of the optic disc due to increased intracranial pressure whihc can be due to icnreased CSF
17
Q
what are the causes of papilloedema
A
- space-occupying lesions
- issues with the CSF system
- blockage of ventricualr system
- obstruction of absorption / drainage
- hypersecretion of CSF from the choroid plexus - benign intracranial HTN , e.g. pseudotumour cerebri
- diffuse cerebral oedema
18
Q
why can papiltloedema be bilateral or unilateral
A
common presentations
- decreased or normal VA
- reduced colour vision
- VF defects (bigger blind spot)
19
Q
papilloedema work-up
A
- VF analysis
- BP (tro malignant HTN)
- Bloods: FBC, glucose, diffrential WCC, UNE, ESR, creatinine, ,autoantimody screen (for MS)
- Neuroimaging for demyelination / compressive lesion (MRI)
- LP (if MRI normal, tro IIH or for demyelination, neurosarcoidosis, lymphoma)
20
Q
what is the most common cause of cn4 palsy
A
trauma (due to the long intracranial course)
presenting as vertical diplopia, hypermetropia on affected side and head tilt to the other side
21
Q
aetiologies of cn3 palsy
A
- medical 3rd - due to diabetes/htn causing the microvascular changes to vasa nevorum, which does NOT supply the pupillomotor fibers (hence pupil sparing)
- surgical 3rd - due to the posterior communicating artery aneurysm, causing compressive effects on the blood vessel in the pia, which supplies the pupillomotor fibres cn3 (pupil is also involved - myadriasis)
22
Q
35M, presenting with sudden onset (24h) hearing loss.
A
idiopathic sensorineural haering loss
23
Q
25M, 2y hx of progressive hearing loss, intermittent otorrhoea in the left ear.
A
conductive hearing loss
24
Q
what does type A, B and C show on the tympanogram
A
type A; normal
type B: no movement in response to pressure in middle ear - suggests middle ear effusion
type C: middle ear has negative pressure, e.g. in chronic ET tube dysfunction
25
which population more associated with horizontal ET
children have more horizontal, otitis media is the most common ear infection in children
trisomy 21, cerebral palsy - musculature around the ET tube does not work as well as it should
chronic ET dysfunction in 1%, treat with steroids sprays and drops nasal at the ET opening
26
indications for grommet insertion
1. otitis media with effusion (OME): accumulation of fluid in the middle ear, can manifest as conductive hearing loss, infections
- both ears for 3m or one year for 6m
2. recurrent acute otitis media for > 4 times a year or > 3 times in 6 month
3. speech delay in children
27
cx and indications for tympanoplasty
indications:
1. TM perforation repair (trauma or iatrogenic) - can present with otalgia, otorrhea, persistent fluid accumulatino in the nasopharynx and conductive hearing loss
cx:
1. general
2. otorrhea, exacerbation of hearing (both an indication and cx)
3. tinnitus
4. facial nerve palsy, chorda tympani
graft from the temporalis fascia or tragus
28
cx and indicatinos for mastoidectomy
indications:
1. mastoiditis (chronic as acute is treated with excise, drain and cover with broad spectrum antibiotics)
2. cholesteatoma (chronic omitis media)
3. tumours of the tmeporal bone
cx:
1. general
2. hearing loss, tympanic membrane perforation
3. facial nerve injuries
4. veritgo, tinnitus
5. CSF leak
29
cx and indicatios for adenoidectomy
indications:
1. recurrent adenoidits
2. OSA
4. recurrent or persistent OME (over 3-4y)
cx:
1. general (esp post-op haemorrhage)
2. epistaxis
3. damage to teeth, tongue, TMJ (due to teh boyle-davis gage)
30
cx and indications for tonsillectomy
indications:
1. recurrent tonsilitis
2. > quinsies (peritonsillar abscess, p/w difficulty opening the mouth, tx with excise, drain and cover with broad spec antibiotics)
3. tonsillar assymetry (tro lymphoma)
4. tonsiliths
5. stridor or enlargement secondary to tonsil enlargement
paradise criteria (7 episodes of tonsilitis over 1y), 6 episodes over 2y or 5 episodes over 3y (requiring avs)
cx:
1. general: bleed - 1 in 10 get a small bleed
2, damage to teeth, tongue and TMJ due to the boyle-davis gagge
31
what is the most common cause of tinnitus
unilateral tinnitis - acoutic neuronma
but can also be due to Covid, medications, S/E of tympanoplasty, mastoidectomy and Meniere’s disease
Imaging: MRI tro acoustic neuroma (aka vestibular schwannoma), which is a noncancerous tumour that develops on CN8, causing tinnitus, sensorineural hearing loss and vertigo. NB can also cause facial numbness if CN7 compressed.
32
what is the cause of unilateral effusion or unilateral otorhhea
in chinese 60% of NPC presenting as
in caucasians is lymphoma, but also more likely to be due to ET tube dysfunction
in smokers (if 1 otalgia) the carcinoma
but also OME, chronic supprative OM
33
cause of unilateral otalgia
referred pain (secondary otalgia) from temporal or teeth, e.g. TMJ dysfunciton, dental infectinos, trigeminal neuralgia, tonsilits, sinusitis
34
when is partial adenoidectomy/tonsillitis indicated
obese kids or kids with trisomy 21.
- higher risk of post-op complicatinos
- more likely to suffer from OSA due to excess soft tissue in throat
- trisomy 21: smaller airways, partial remove more beneficial
- slower abliity to heal (faster recover), wth lower pain tolernace (less pain)
35
what is the classic presentation of otoscleoris
- pregnant female caucasian
- progressive conductive hearing loss
- tinnitus, mild vertigo
- paracusis willisii (hearing better in noisy than quiet)
36
what are the causes of otitis externa
Causes: due to bacterial or viral infections, 90% due to bacterial (Pseudomonas aeruginosa, S. aureus), 10% fungal (Candida, Aspergillus)
it is the most common ear infection in adults (middle ear for children), and affects 5-10% of the population, especially individuals with skin conditions.
37
triad of meniere;s disease
vertigo
tinnitus
hearing loss (SNHL, fluctuating)
38
causes of unilateral otalgia referred pain (secondary)
- tmj dysfunctions
- teeth infectinos
- tonsilitis
- sinusitis
- trigeminal neuralgia
39
mx of otitis extern
Cleaning and removal of ear wax, desquamated skin and purulent material by gentle mopping or suction
Mx includes admitting the patient and giving IV Abx
Topical steroids (Dexamethasone, for 48h, decongest the canal and reduce swelling and inflammation)
Topical Abx
Antifungal medication (if otomycosis)
Analgesics
40
50M, 1y hx of bilateral nose blockage and hyposmia. DDx and mx? (2021)
chronic rhinosinusitis
41
fractured nasal bone plan
Plan
Wait 7-21 days for swelling / oedema to settle
Manipulate back into position (MNB: Manipulation of Nasal Bone) optimal window is 7-14 days as bone will harden and set, then it will be difficult to manipulate after that
TRO Septal Haematoma
Mucoperichondrium separates from skin and blood fills this potential space (blood is from mucosal supply, nasal septum + pinna cartilage is avascular
Tx by incision, drainage and broad spectrum antibiotics
Cx: saddle nose deformity (but saddle nose is also characteristic of GPA)
42
what is the blood plexus most involved in epistaxis
kiesselbachs (90%) vs woodruff (10%)
43
what is HHT
Hereditary Hemorrhagic Telangiectasia (HHT) is a hereditary systemic vasculopathy, characterised by telangiectasia on the skin and mucosa, especially in the face (nose, lips and tongue). Telangiectasia (small, dilated blood vessels) and AVM formations (shunting between arteries veins)
Diagnostic criteria: Curaçao criteria (definite HHT if 3 or more, possible if 2)
Spontaneous, recurrent epistaxis
Multiple telangiectasia
Visceral AVMs (lung, liver, brain, GIT)
Fam hx
Clinical features: recurrent epistaxis, telangiectasia, cyanosis
Mx: same as epistaxis above, embolization for large pulmonary and hepatic AV fistulas. Cx is high output HF, paradoxical emboli and chronic GI bleeding or haematuria (anaemia).
44
what are the causes of hoarseness
Causes of hoarseness:
C: Congenital - rare
I: Infection, Iatrogenic, Idiopathic
Infection - e.g. in acute laryngitis
Iatrogenic - e.g. thyroidectomy-induced RLN palsy
Idiopathic
T: Trauma - e.g. vocal cord abuse, cysts, papillomas, nodules
T: Toxins - steroid inhalers for COPD patients
E: Endocrine - e.g. hypothyroidism
N: Neurogenic, Neoplasm
Neurogenic - MG, PD, psychogenic
Neoplasm - e.g. oropharyngeal cancer, laryngeal cancer in smokers. Hoarseness in smokers for more than 3 weeks is cancer (laryngeal SCC) until proven otherwise.
45
5y/o presents with midline mass on neck, what is the most likely diagnosis and management (2024)
Thyroglossal duct cyst is the most common congenital midline abnormality of the neck. It is the embryological remnant of the thyroglossal duct as it descends form the foramen cecum.
Presentation: lump on midline of throat, moves when the tongue moves as it is attached to the hyoid bone. It is typically benign, but should be taken out as it can get infected and form a fistula, which will be difficult to excise.
Tx: Sistrunk’s procedure, which can decrease the recurrence rate to 3%.
46
40y/o woman with a right-sided 2cm neck swelling, differentials and investigations. (2024)
Branchial cleft cyst is the most common congenital lateral neck mass. Typically presents in the late 20’s or early 30’s. It is caused by the failure of fusion of 2nd and 3rd branchial arches.
Presentation: cystic mass on lateral side, asymptomatic, but might be infected over time.
Tx: total surgical excision
47
35F, euthyroid, presenting with asymptomatic 2cm discrete thyroid swelling, how should it be managed? (2007, 2008)
If > 1 cm, then
Clinical history and exam, asking about symptoms, risk factors and red flags (which is hoarseness, fixed mass, cervical lymphadenopathy)
TFTs (usually euthyroid)
U/S (to determine if it is cystic or solid): visualise the size and regularity of margins, cystic nodules are more likely to be benign.
Tissue FNA
Do Thy staging from FNA findings.
AGES: age > 40y in male, > 45y in female , gender, extracapsular spread, and size (if > 4cm)
48
indications and complications for parathyroidectomy
Indications: primary hyperparathyroidism, the most common cause of benign adenoma in one PTH gland (85%), followed by hyperplasia of all the glands. Patient would be presenting with hypercalcaemia and hyperPTH, stones, bones, moans, and psychic moans.
Complications: **similar to thyroidectomy
General
HypoPTH
HypoCa (usually transient due to transient ischaemia of the other gland)
Failure of procedure, leading to hyperCa
SLN and RLN damage
49
indications for thyroidedcomy
1. malignancy
2. large, multinodular goiter causing compressive symptoms
4. hyperT refractory to medical treatment
4. cosmesis
50
complications of thyroidectomy
- general: ga, infection, haematoma, failure
- hypoPTH and hypoCa
- haematoma ** emergency
- RLN and SLN damage
- hypothyroisism
51
how is sialoithiasis/sialadenitis managed? and wha are the complications of this?
sialendoscopy, or submandibular gland excision
- damage to teh lingual, hypoglossal nerve and marginal mandibular branch of the facial nerve
52
what is the 80/20 rule for parotid gland tumours
1. tumour will be 80% benign
2. tuomur will be 80% superficial
vs submandibular is 50/50
vs minor salivary glands 20/80
53
what are the salivary gland tumours
benign
intermediate
malignant
benign: pleomorphic adenoma, Warthin's tumour
intermediate: mucoepidermoid
malignant: adenoid cystic, acinic cell carcinoma
54
what is frey's syndrome
facial sweating and flushing when eating, common complication of paroidectomy
- due to damage to the auriculotemporal nerve (mandibular branch of the trigeminal nerve CN5)
55
indications and complications of paroidectomy
Indications: benign parotid swelling (e.g. pleomorphic adenoma) or malignant parotid tumour.
Complications:
General: GA, haematoma, infection, failure
Recurrence
Haematoma, seroma
3 F’s: Frey’s syndrome, Fistula, Facial nerve damage
56
what are the indications for tracheostomy
1. upper airway obstruction (can be due to FB, anaphylaxis, inhalation burns, tumours, oedema)
2. chronic debilitating neurological conditions (e.g. PD, MG) where the patients are not able to clear their own secretions
3. prolonged ventilation or intubation requirement
57
complications of trachoestomy
Immediate (operative): GA, haemorrhage, air embolism, damage to the adjacent structures (e.g. cricoid cartilage), pleural domes and RLN
Intermediate (within 2 weeks)
Blockage or displacement of the tube
Pneumothorax
Neck emphysema, chest or wound infection
Delayed
Subglottic, tracheal stenosis
Tracheocutaneous fistula
Tracheomalacia
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