Neurology & Special Senses Block

Question 1

What are the components of a systems review from a neurological point of view? (8)

Answer 1

1. Vision
2. Smell
3. Taste
4. Headache
5. Fits, faints, funny turns
6. Hearing
7. Speech + swallow
8. Sensation
9. Balance + coordination
10. Incontinence/erectile dysfunction
11. Memory

Question 2

What are 4 important aspects to focus on in a neurological history?

Answer 2

1. Timeline of symptoms in presenting complaint
2. Neurological systems review
3. Detailed family history of multiple generations
4. Determining the impact of the disease on patient’s life

Question 3

What 3 symptoms are associated with cluster headaches?

Answer 3

1. Eye watering
2. Eye infection
3. Nasal congestion

**Unilateral autonomic involvement

Question 4

What 4 symptoms are associated with migraine?

Answer 4

1. Photophobia
2. Aura symptoms
3. Phonophobia
4. Nausea/vomiting

Question 5

What is the headache differential for:

Tight, band-like sensation, precipitated by stress

Answer 5

Tension headache

Question 6

What is the headache differential for:

Brief, stabbing pain when brushing teeth or chewing

Answer 6

Trigeminal neuralgia

Question 7

What is the headache differential for:

Photophobia, neck stiffness, fever

Answer 7

Meningitis

Question 8

What is the headache differential for:

Sudden onset, excruciating headache

Answer 8

Subarachnoid hemorrhage

Question 9

What is the headache differential for:

Facial tenderness, rhinorrhea

Answer 9

Sinusitis

Question 10

What is the headache differential for:
Unilateral, pounding, multiple triggers, lasts for hours, aversion to bright lights and loud noises, can be preceded by aura

Answer 10

Migraine

Question 11

What is the headache differential for:

20min unilateral, debilitating episodes of retro-orbital pain with red eye + eye watering

Answer 11

Cluster headache

Question 12

What is the headache differential for:

Headache triggered by changes in position/exertion, Changes in vision with leaning forward

Answer 12

Increased intracranial pressure

Question 13

What is the headache differential for:

Pain around eye, blurred vision with halos around lights

Answer 13

Acute glaucoma

Question 14

What is the headache differential for:

Scalp tenderness, unilateral, jaw claudication

Answer 14

Temporal arteritis

Question 15

What are the NICE Guidelines headache red flags? (10)

Answer 15

1. Sudden onset high severity headache
2. Headache with fever
3. New onset neurological deficit
4. New onset cognitive dysfunction
5. Change in personality
6. Impaired level of consciousness
7. Recent head trauma (within past 3mo)
8. Headache triggered by cough, sneeze, exercise, or changes in posture
9. Headache associated with halos around lights, or headaches that get worse in the dark
10. Headache associated with jaw claudication + scalp tenderness

Question 16

What is the acute and prophylactic treatment used for cluster headache? (2)

Answer 16

Acute = 100% high flow oxygen (12L/min) with non-rebreathe mask + reservoir bag

Prophylactic = Verapamil

Question 17

What is the acute and prophylactic treatment used for migraine? (4)

Answer 17

Acute = NSAIDs, Paracetamol, Oral triptan

Prophylactic = Propranolol

Question 18

What is the loss of consciousness differential for:

Triggered by suddenly standing up

Answer 18

Postural hypotension

Question 19

What is the loss of consciousness differential for:

Chest pain, breathlessness, and collapse on exertion

Answer 19

Aortic stenosis

Question 20

What is the loss of consciousness differential for:

Palpitations/chest pain beforehand, family history of sudden unexplained death

Answer 20

Arrhtyhmia/cardiogenic syncope

Question 21

What is the loss of consciousness differential for:
Triggered by fear, pain, micturition, or prolonged standing. Preceeded by pallor, nausea, or sweating. No confusion afterwards

Answer 21

Vasovagal syncope

Question 22

What is the loss of consciousness differential for:

Triggered by vigorous exercise in a young person

Answer 22

Hypertrophic cardiomyopathy/cardiogenic syncope

Question 23

What is the loss of consciousness differential for:

Collapse on shaving or turning head

Answer 23

Carotid sinus hypersensitivity

Question 24

What is the loss of consciousness differential for:

Being told off by teachers for seemingly daydreaming

Answer 24

Absence seizure

Question 25

What is the loss of consciousness differential for: | Pale and sweaty beforehand, jerking of limbs, eyes rolled back, short duration of episode, no confusion afterwards

Answer 25

Vasovagal syncope

Question 26

What is the loss of consciousness differential for: | Twitching and jerking in the morning

Answer 26

Early morning myoclonus

Question 27

What is the loss of consciousness differential for: Crying out, falling to the floor, period of stiffness followed by rhythmic jerking that gradually decreases in amplitude and frequency, period of confusion for 30min afterwards

Answer 27

Generalised tonic-clonic seizure

Question 28

What is the loss of consciousness differential for: | Violent shaking, head moving side to side, arching back, episodes of stillness before starting again, forced eye closure

Answer 28

Psychogenic non-epileptic attack

Question 29

Give 2 examples of LMN pathology that can be seen at the end of the bed when examining the patient?

Answer 29

1. Fasciculations | 2. Muscle atrophy

Question 30

What does a pale optic disk indicate? (1)

Answer 30

Previous optic neuropathy

Question 31

What does the swinging torch test assess? (1)

Answer 31

Relevant Afferent Pupillary Defect (RAPD)

Question 32

What is a Relevant Afferent Pupillary Defect?

Answer 32

Paradoxical pupil dilatation observed in the affected eye | sign of damage to the optic nerve of the affected eye, which indicates optic neuropathy

Question 33

What are saccades?

Answer 33

Rapid eye movements between 2 targets

Question 34

What pathology can cause slow/restricted saccades? (1)

Answer 34

Progressive supranuclear palsy

Question 35

What nerves are assessed in the corneal reflex test? (2)

Answer 35

1. Trigeminal nerve (CN 5) = afferent | 2. Facial nerve (CN 7) = efferent

Question 36

Give 2 examples where you'd observe weakness of the facial nerve (CN 7) in a neurological examination?

Answer 36

1. Bell's palsy (LMN - facial paralysis) | 2. Stroke (UMN - forehead sparing due to bilateral innervation)

Question 37

What nerves are tested in the gag reflex? (2)

Answer 37

1. Glossopharyngeal nerve (CN 9) = afferent | 2. Vagus nerve (CN 10) = efferent

Question 38

What does pronator drift indicate? (1)

Answer 38

UMN lesion in pyramidal tracts

Question 39

When assessing tone in a patient, what is the difference between spasticity and rigidity, and give 1 example of a condition with each?

Answer 39

Spasticity = stiffness exacerbated when attempting to move the limb quickly (i.e. pyramidal lesion = UMN pathology) Rigidity = stiffness that remains throughout entire movement (i.e. extrapyramidal lesion = PD)

Question 40

In what situations are reflexes exaggerated? Decreased/absent? (2)

Answer 40

Exagerrated = UMN pathology Decreased/absent = LMN pathology

Question 41

What 2 tests done in a neurological examination assess the dorsal columns?

Answer 41

1. Proprioception test | 2. Vibration test

Question 42

What tests are done in a neurological examination to assess the spinothalamic pathway? (2)

Answer 42

1. Pinprick test | 2. Sensation with cotton wool

Question 43

What additions would need to be made to the basic neurological examination in a patient with suspected Parkinson’s disease? (4)

Answer 43

1. Observe for "pill-rolling tremor" (easiest to visualize with a distracting task - get pt to close eyes + count down from 20) 2. Bradykinesia: check speed of movement with finger snapping 3. Check face for hypomimia (expressionless face) 4. Check gait for reduced stride length, reduced arm swing, broken turning

Question 44

How is muscle power assessed using the MRC Grading Scale? (6)

Answer 44

``` 0 = no power 1 = twitching but no movement 2 = movement, but cannot overcome gravity 3 = can overcome gravity 4 = movement against gravity and resistance 5 = normal muscle strength ```

Question 45

What structures are considered upper motor neurone? (3)

Answer 45

CNS structures: 1. Motor cortex 2. Spinal cord 3. White matter tracts

Question 46

What structures are considered lower motor neurone? (4)

Answer 46

PNS structures: 1. Motor nerve 2. Nerve root 3. Neuromuscular junction 4. Anterior horn cell

Question 47

What are signs of UMN pathology? (4)

Answer 47

1. Hypertonia 2. Atrophy 3. Positive Babinksi sign 4. Hyperreflexia

Question 48

What are signs of LMN pathology? (4)

Answer 48

1. Hypotonia 2. Atrophy 3. Fasciculations 4. Hyporeflexia

Question 49

Where do motor nerve pathways cross? (1)

Answer 49

Crosses in the medulla

Question 50

What is a hemi-section of the spinal cord also referred as? (1)

Answer 50

Brown-Sequard syndrome

Question 51

What motor symptoms would you expect to see in Brown-Sequard syndrome? (2)

Answer 51

UMN signs b/c damage to the spinal cord: 1. Increased tone 2. Increased reflexes *Signs will be seen in areas distal to the level of the lesion, and on the ipsilateral side*

Question 52

What sensory symptoms would you expect to see in Brown-Sequard syndrome? (2)

Answer 52

1. Loss of vibration, fine touch, proprioception (ipsilateral to lesion) 2. Loss of temperature and pinprick (contralateral to lesion)

Question 53

In homonymous hemianopia, where is the nerve damage? (2)

Answer 53

Occipital cortex or optic radiation

Question 54

In bitemperal hemianopia, where is the nerve damage? (1)

Answer 54

Optic chiasm

Question 55

In monocular blindness, where is the nerve damage? (1)

Answer 55

Optic nerve

Question 56

Where does the dorsal columns pathway cross? (1)

Answer 56

Medulla

Question 57

Where does the spinothalamic pathway cross? (1)

Answer 57

Spinal cord

Question 58

What are the main investigations used in neurology? (5)

Answer 58

1. CT: identifying acute collections of blood (i.e. SAH, extradural hematoma) 2. MRI: looking for lesions (i.e. MS, tumours) 3. Lumbar puncture: looking for infection/inflammation (i.e. meningitis, encephalitis) 4. EEG (electroencephalography): (i.e. seizures, encephalopathy) 5. Nerve conduction studies/electromyography (EMG): assess neurological structures in PNS

Question 59

A 65 year old male is being reviewed on the stroke ward after returning from radiology. Imaging reveals an ischemic stroke involving the left temporal lobe. What visual field defect would most likely be found upon examination?

Answer 59

R superior quadrantanopia

Question 60

What investigations would you order for a patient with four limb weakness with breathlessness? (10)

Answer 60

1. FBC 2. U&E 3. LFTs, Calcium, Magnesium, Phosphate 4. CRP 5. ESR 6. Chest x-ray 7. Basic spirometry 8. ECG 9. Lumbar puncture 10. MRI of spine

Question 61

What is the first line treatment for Guillain-Barré syndrome? (3)

Answer 61

1. IV immunoglobulin 2. Thromboprophylaxis (TEDs + LMW heparin) 3. Plasma exchange (technically demanding)

Question 62

What are complications of lumbar puncture? (7)

Answer 62

1. Headache (common) 2. Painful paraesthesia 3. Persistent pain/paraesthesia 4. Bleeding 5. Infection (meningitis) 6. Uncal herniation 7. Failure of procedure

Question 63

What are 3 causes of a genuine dry tap when performing a lumbar puncture? (3)

Answer 63

1. Arachnoiditis 2. Meningeal infiltration 3. True low CSF pressure

Question 64

At what level is a lumbar puncture performed? (2)

Answer 64

1. Between L3-L4 | 2. Between L4-L5

Question 65

What lumbar puncture result would suggest Guillian-Barré syndrome? (1)

Answer 65

Normal cell count but elevated protein level ('cytoalbuminologic dissociation')

Question 66

What are the 6 Guillian-Barré syndromes?

Answer 66

1. AIDP (acute inflammatory demyelinating polyradiculoneuropathy) 2. AMAN (acute motor axonal neuropathy) 3. AMSAN (acute motor + sensory axonal neuropathy) 4. Miller-Fisher syndrome 5. Pure sensory neuropathy 6. Acute pandysautonomia

Question 67

What are the 5 features that all Guillian-Barré syndromes have in common?

Answer 67

1. Acute/sub-acute, monophasic PNS disorders (peak disability <4 weeks; 4-8 weeks) 2. Antecedent "trigger" 3. Areflexia 4. CSF "albuminocytologic dissociation" (increased protein with normal cell count) 5. Generally spontaneous recovery occurs

Question 68

What are the features of AIDP (Guillian-Barré syndrome)? (5)

Answer 68

1. Begins with paraesthesia + pain (50%) 2. Followed by muscle weakness first in legs (10% in arms first) 3. Facial nerve commonly involved + ophthalmoplegia 4. Autonomic manifestations (labile BP, arrhythmia, constipation, abdominal distention) 5. Progresses days to 4 weeks

Question 69

How is Guillian-Barré syndrome diagnosed? (2)

Answer 69

1. CSF "albuminocytologic dissociation" | 2. Nerve conduction studies (increased F-wave latency)

Question 70

What is the pathophysiology of Guillian-Barré syndrome? (1)

Answer 70

Demyelination of peripheral nerves

Question 71

What can trigger Guillian-Barré syndrome? (4)

Answer 71

1. Infections (CMV, HIV) 2. Systemic illnesses (Hodgkin's disease) 3. Bacterial + Parasites (Campylobacter Jejuni) 4. Other medical conditions (Pregnancy, surgery)

Question 72

What is the most common form of Guillian-Barré syndrome in the developed world?

Answer 72

AIDP (acute inflammatory demyelinating polyradiculoneuropathy)

Question 73

What is the prognosis of Guillian-Barré syndrome? (3)

Answer 73

1. Mortality 3-5% 2. 15% severe disability 3. 80% recover within 6mo

Question 74

What are 4 general indications for a lumbar puncture?

Answer 74

1. Headache 2. Infection (i.e. meningitis) 3. Inflammation (i.e. transverse myelinitis, Guillian-Barré) 4. Cancer

Question 75

What are the 5 key measurements of CSF, and what are their normal levels?

Answer 75

1. Opening pressure (only accurate when pt lying laterally on couch) = <20cm 2. White cell count = <5WBC 3. Red cell count = none 4. Protein = <0.45g/L 5. Glucose = approx 2/3 of plasma (check plasma glucose at same time)

Question 76

What are 6 extra tests that can be performed with a lumbar puncture?

Answer 76

1. Microbiological stains 2. Culture + sensitivity 3. Viral/bacterial PCR 4. Oligoclonal bands (MS) 5. Cytology 6. Spectrophotometry/xanthochromia (SAH)

Question 77

What do the key measurements of CSF look like in a bacterial infection? (4)

Answer 77

1. High opening pressure 2. Neutrophils present 3. High protein 4. Low glucose

Question 78

What do the key measurements of CSF look like in a viral infection? (4)

Answer 78

1. Normal opening pressure 2. Lymphocytes present 3. High protein 4. Normal glucose

Question 79

What do the key measurements of CSF look like in a TB infection? (4)

Answer 79

1. High/very high opening pressure 2. Lymphocytes present 3. High/very high protein 4. Very low glucose

Question 80

What do the key measurements of CSF look like in a fungal infection? (4)

Answer 80

1. Very high opening pressure 2. Lymphocytes present 3. High protein 4. Low glucose

Question 81

What would the CSF analysis look like in cancer? (3)

Answer 81

1. High WBC + protein 2. Very low glucose 3. Abnormal cytology

Question 82

What would the CSF analysis look like in subarachnoid hemorrhage? (2)

Answer 82

1. High RBC | 2. Xanthochromia (raised bilirubin + oxyhemoglobin)

Question 83

In what infection do you see raised RBC count (hemorrhagic CSF)?

Answer 83

Herpes simplex encephalitis | commonest viral encephalitis

Question 84

What is the normal nerve speed of a motor nerve?

Answer 84

>49m/s | if <49m/s = problem with the myelin sheath around the nerve

Question 85

What are the key features in the initial presentation of Acute Cervical Cord Syndrome? (5)

Answer 85

1. Mixture of 4 limb motor + sensory weakness 2. Sphincteric syndromes (bladder urgency/frequency) 3. Pain 4. Increased tone + reflexes (although in very acute setting = flaccid + absent reflexes = 'spinal shock') 5. May just involve posterior cord = no motor signs = sensory ataxia

Question 86

What are the key features in the initial presentation of Cauda Equina Syndrome? (6)

Answer 86

1. Lower limb symptoms + signs, with normal upper limbs 2. Combo of motor + sensory problems 3. Bladder disturbance 4. Saddle anaesthesia 5. Pain 6. Examination will reveal LMN signs only!

Question 87

What are the key features in the initial presentation of Myasthenia Gravis? (4)

Answer 87

1. Muscle weakness (no sensory problems) 2. Typically include eyes, mouth, proximal limbs 3. Respiratory muscles may be involved = breathlessness when lying down b/c of weak diaphragm 4. Weakness is fatiguable (i.e. worse late in day, after exercise)

Question 88

What are the key features in the initial presentation of Acute Myositis? (3)

Answer 88

1. Proximal limb muscle weakness 2. Pain 3. Normal reflexes + sensation

Question 89

A 25 year old man presents to A+E with a 3 day history of weakness and numbness affecting the hands and feet. He has no change in vision, speech or swallowing. He has noticed some increasing urinary frequency and urgency. What is the most likely anatomic site affected by pathology?

Answer 89

Cervical spine - He has 4 limb symptoms + urinary disturbance

Question 90

A 25 year old man presents to A+E with a 3 day history of weakness and numbness affecting the hands and feet. He has no change in vision, speech or swallowing. On examination he is alert and has normal cranial nerves. Limb exam reveals normal tone, weakness, absent reflexes and reduced sensation distally. What is the most likely cause for these problems?

Answer 90

Acute polyneuropathy - Would account for the rapid onset of 4 limb symptoms + LMN signs on exam

Question 91

A patient with rapid onset weakness affecting all 4 limbs undergoes a lumbar puncture. The following results are available: - Opening pressure 17cm - WBC 4 - RBC <1 - Protein 0.9g/L - Glucose 3.6 mmol/L (serum 6.0 mmol/L) Which diagnosis these results support?

Answer 91

Guillian-Barré Syndrome - Cytoalbuminologic dissociation (high protein count) is seen here

Question 92

A 72 year old lady has been complaining of intermittent diplopia to her GP. Whilst waiting for an appointment with the ophthalmologists she develops problems in swallowing and difficulty rising from a chair unaided. When admitted to hospital she is found to have bilateral ptosis and facial weakness. She is dysarthric. She has normal tone and reflexes in the limbs but proximal weakness that gets worse during the course of the assessment. What's the most likely diagnosis?

Answer 92

Myasthenia Gravis

Question 93

A 25 year old man presents to A+E with a 3 day history of weakness and numbness affecting the legs and feet. Examination reveals normal cranial nerves and upper limbs. In the lower limbs there is increased tone, brisk reflexes, upgoing plantars and grade 4 power in all muscle groups tested. Sensation to pinprick is altered throughout the legs and pelvic area. Joint position sense seems intact. What's the most useful diagnostic test?

Answer 93

MRI thoracic spine - MRI thoracic spine is most likely to reveal the underlying cause as the symptoms and signs are compatible with a thoracic myelopathy.

Question 94

What are possible treatments for Bell's palsy? (2)

Answer 94

1. Steroids (prednisolone) | 2. Aciclovir (weak evidence)

Question 95

How long does it take for Bell's palsy to resolve?

Answer 95

4-6 months (recurrence is uncommon)

Question 96

What are possible causes of Bell's palsy? (2)

Answer 96

1. Inflammation | 2. Viral infection

Question 97

What is Ramsay Hunt syndrome? (4)

Answer 97

1. Herpes zoster ("shingles") of the geniculate ganglion of the facial nerve 2. Associated with painful vesicles affecting the external ear and occasionally on the palate 3. Treated with acyclovir + high-dose steroids 4. Important differential for Bell's palsy

Question 98

In what settings is a Left Common Peroneal Nerve Palsy common? (1)

Answer 98

1. Prolonged/repeated knee flexion (i.e. kneeling)

Question 99

What movements is the common perineal nerve responsible for? (2)

Answer 99

1. Ankle dorsiflexion (innervates tibialis anterior) | 2. Foot eversion (innervates peroneal muscles)

Question 100

What muscle and nerve are responsible for foot inversion? (2)

Answer 100

1. Tibialis posterior | 2. Tibial nerve

Question 101

When there is weakness of ankle inversion and eversion, + loss of ankle reflex what is the likely diagnosis? (1)

Answer 101

1. Prolapsed ('slipped') intervertebral disc causing compression of the L5 and S1 nerve roots

Question 102

What investigations are useful to confirm the diagnosis of foot drop? (3)

Answer 102

1. Nerve conduction studies 2. Ultrasound 3. MRI/CT

Question 103

What is the treatment for foot drop? (1)

Answer 103

1. Footdrop splint (ankle foot orthosis)

Question 104

How long will a foot drop take to heal depending on the cause of injury? (2)

Answer 104

1. Demyelination lesions = full recovery within weeks | 2. Axonal loss = longer, and likely incomplete recovery

Question 105

What is the typical presentation of a radial nerve palsy?

Answer 105

Wrist drop - Typically due to the compression of the radial nerve against the mid-shaft of the humerus - Neurophysiology can be helpful to confirm diagnosis - Wrist drop splint used for treatment

Question 106

What features on a neurophysiological study would indicate there's a conduction block? (2)

Answer 106

1. Poorly formed waveform | 2. Lower amplitude of the waveform

Question 107

What is the recommended treatment for Bell's palsy? (1)

Answer 107

Oral prednisolone 60mg for 1 week

Question 108

In UMN facial weakness, what can be observed on examination? (1)

Answer 108

Sparing of the forehead

Question 109

What are the 3 features of Ramsay Hunt syndrome?

Answer 109

1. Pain 2. Vesicular rash 3. Facial palsy

Question 110

A 55 year old man with a history of chronic back pain presents with 2 weeks of worsening back pain. This morning he noticed he was tripping on his right foot. On examination the cranial nerves and upper limbs are normal. In the lower limbs there is normal tone but weakness of right foot dorsiflexion. Reflexes are present at the knee but absent at both ankles. There is reduced pin prick sensation on the lateral border of the right shin. What's the likely diagnosis?

Answer 110

L5/S1 radiculopathy

Question 111

What are 3 triggers for seizures?

Answer 111

1. Severe illness 2. Dehydration 3. Overtiredness

Question 112

What are 5 features that typically occur during an epileptic seizure?

Answer 112

1. Pain 2. Injuries 3. Tongue biting 4. Fecal/urinary incontinence (urinary incontinence also common in vasovagal syncope, esp in women) 5. Cyanosis of the lips

Question 113

What happens to the jerking movements during a generalized tonic-clonic seizure? (1)

Answer 113

They reduce in amplitude and frequency during the attack

Question 114

What is the typical duration of a generalized tonic-clonic seizure?

Answer 114

5min If longer = status epilepticus or non-epileptic attack disorder

Question 115

In what condition is prolonged unresponsiveness/'pseudo sleep' seen? (1)

Answer 115

Non-epileptic attack disorder (NEAD)

Question 116

Name 2 metabolic disturbances that can give rise to seizures?

Answer 116

1. Hyponatremia | 2. Hypocalcemia

Question 117

What investigations should be ordered for someone with a transient loss of consciousness? (6)

Answer 117

1. Vital signs 2. Blood glucose 3. ECG 4. Neurological examination 5. Bloods (U&Es) 6. CT head

Question 118

What is a simple partial seizure? (2)

Answer 118

1. Uncontrollable twitching of which the patient is fully aware 2. May be able to communicate normally throughout the event

Question 119

What is a complex partial seizure? (2)

Answer 119

1. Abnormal uncoordinated electrical discharges are confined to one area of the brain 2. Awareness is impaired during the event (even though the patient may not lose consciousness completely + may partially remember the events afterwards)

Question 120

What are the symptoms of a temporal lobe seizure? (6)

Answer 120

1. Memory disturbances (i.e. deja vu) 2. Olfactory + auditory hallucinations 3. Epigastric sensations 4. Fear 5. Bizarre psychic phenomena (i.e. derealisation, depersonalization, attacks of elation) 6. Automatisms (i.e. lip-smacking, repetitive mumbling)

Question 121

What are possible risk factors for developing epilepsy? (8)

Answer 121

1. Birth history (prematurity, difficult delivery - forceps, postnatal difficulties - hypoxia, jaundice) 2. Childhood milestones/developmental delays 3. Seizures in childhood/infancy 4. Significant head injuries 5. History of CNS infections (meningitis, encephalitis, abscess) 6. Family history of epilepsy 7. Medications (some lower seizure threshold) 8. Recreational drugs/alcohol

Question 122

What is a prolonged febrile convulsion? (3)

Answer 122

1. Typically occur around 18mo 2. Associated with high fever 3. Risk factor for developing epilepsy in later life (originating in temporal lobes)

Question 123

What changes are evident in epilepsy due to previous prolonged febrile convulsions in the temporal lobes on MRI? (2)

Answer 123

1. Atrophy 2. Scarring (glosis) = high signal on MRI = Mesial Temporal Sclerosis (MTS)

Question 124

Which anticonvulsant drug requires close monitoring with blood tests?

Answer 124

Phenytoin b/c there's a close correlation between serum level + efficacy

Question 125

What are the 3 features of fetal valproate syndrome?

Answer 125

1. Dysmorphia 2. Developmental delay 3. Cognitive impairment

Question 126

What are the possible complications associated with sodium valproate use? (2)

Answer 126

1. Major congenital defects (spina bifida, anencephaly) | 2. Fetal valproate syndrome

Question 127

What are the 4 issues of switching anticonvulsant medications?

Answer 127

1. Avoiding breakthrough seizures (titrate down old drug) 2. Tolerability of new drug (possible side effects) 3. Potential drug interactions (esp OCP) 4. Implications for driving (DVLA must be informed + withhold license for at least 6mo)

Question 128

When changing anticonvulsant drugs, what are the implications for driving? (2)

Answer 128

1. Must stop driving for at least 6mo + inform the DVLA | 2. DVLA recommend stop driving for the changeover period + 6mo afterwards (not legally enforced)

Question 129

What are the 4 common side effects of lamotrigine?

Answer 129

1. Sedation 2. Dizziness 3. Nausea 4. Insomnia

Question 130

What are 2 serious side effects of lamotrigine?

Answer 130

1. Allergic skin rash 2. Severe multi-system hypersensitivity reaction with fever + multi-organ failure (Steven-Johnson's Syndrome) **Interaction with sodium valproate can lead to #2!

Question 131

What precautions must be taken for a women on anticonvulsants wishing to get pregnant? (3)

Answer 131

1. Lowest possible dose of anticonvulsant 2. Avoid unplanned pregnancy 3. Take prophylactic folic acid 5mg/day as soon as contraception is stopped and through the 1st trimester

Question 132

What factors can reduce seizure threshold? (8)

Answer 132

1. Intercurrent illness 2. Missing medication 3. New medication that interacts with anticonvulsants (i.e. tramadol, amitryptiline) 4. Alcohol excess 5. Recreational drug use 6. Metabolic disturbances (hyponatremia, hypoglycaemia) 7. Insomnia, fatigue, jetlag 8. GI disturbances (impair anticonvulsant absorption)

Question 133

What are the driving implications after having a seizure?

Answer 133

Must inform the DVLA + license is withheld until the patient has been seizure-free for 1 year

Question 134

What are the possible treatments for medically refractory epilepsy? (2)

Answer 134

1. Try different anticonvulsants (polypharmacy with 2+ AEDs may work) 2. Epilepsy surgery (if a well-defined structure in the brain is responsible for the seizures that could be resected without neurological deficit)

Question 135

What is the treatment pathway for status epilepticus? (3)

Answer 135

1. Benzodiazepine (IV lorazepam/diazepam; buccal/IM midazolam) -> if fitting for > 5min 2. IV antiepileptic agent (Sodium Valproate/Phenytoin) -> if no response to step 1 within 10min 3. General anaesthesia (Propofol) -> no response to step 2 within 30min

Question 136

What general medical measures must be done when treating an epileptic patient? (10)

Answer 136

1. Secure airway + resuscitate 2. Administer oxygen 3. Assess cardiorespiratory function 4. Establish IV access (2 large bore cannulas) 5. Measure blood glucose + correct immediately 6. Check temperature 7. Check blood gases 8. If poor nutrition/alcoholism give Pabrinex/Thiamine 9. If woman of childbearing age, consider pregnancy test 10. Bloods (FBC, U+E, Glucose, Ca2+, Mg2+, CK, LFTs + INR, anti-epileptic drug level, alcohol/toxicology screen, culture if appropriate)

Question 137

What is a good first line antiepileptic drug for someone on Warfarin?

Answer 137

Levetiracetam (doesn't interact with warfarin)

Question 138

A 45 year old patient presents to hospital having had a first ever attack of loss of consciousness and limb shaking. They have recovered well and should be able to go home the same day. What is the most important investigation to perform before discharge? (1)

Answer 138

ECG

Question 139

Where is the lesion to cause loss of vision in one eye? (3)

Answer 139

Anterior to the optic chasm: 1. Optic nerve 2. Retina 3. Eye itself

Question 140

What is an relative afferent pupillary defect and how is it explained by the neuroanatomy of the pupillary light reflex? (2)

Answer 140

1. In normal circumstances the pupil remains constricted because of equal direct (light shone into that eye) or indirect (light shone into the other eye) stimulation. 2. In an eye affected by optic neuropathy the pupil paradoxically dilates when light is shone into that eye as the direct stimulus (light via ipsilateral damaged optic nerve) is weaker than the indirect stimulus (light via intact contralateral optic nerve)

Question 141

Where is the lesion that causes RAPD? (1)

Answer 141

Damaged cranial nerve 2 (optic neuropathy)

Question 142

What conditions can lead to RAPD? (2)

Answer 142

1. Optic neuritis | 2. Multiple sclerosis (retrobulbar optic neuritis) -> recovery in 3-4 weeks

Question 143

What is the pathophysiology of retrobulbar optic neuritis? (1)

Answer 143

1. Autoimmune attack on the optic nerve

Question 144

What systemic conditions may result in optic neuritis? (4)

Answer 144

1. Vitamin B12 deficiency 2. Systemic multisystem inflammatory conditions (i.e. SLE, GPA, EGPA, Antiphospholipid Syndrome, Sarcoidosis) 3. Infectious triggers (HIV, Syphilis, Hepatitis B/C) -> rare 4. Rare conditions (Neuromyelitis optica, Devic's disease)

Question 145

What blood tests would you order for someone diagnosed with optic neuritis? (5)

Answer 145

1. Serum B12 levels 2. Nonspecific markers of inflammation (ESR/CRP, serum electrophoresis) 3. Immunological tests (ANA, ANCA, ds-DNA, ENA, anticardiolipin antibodies, serum ACE levels) 4. Serology for infections (HIV, syphilis, Hep B, Hep C) 5. Specific antibodies for rare conditions (aquaporin 4 antibodies)

Question 146

What result on MRI would be indicative of optic neuropathy due to multiple sclerosis? (2)

Answer 146

1. Swelling + high signal within the optic nerve | 2. High signal lesions within the periventricular white matter (radiologically consistent with demyelination)

Question 147

What is the typical orientation of a demyelination lesion on MRI (i.e. multiple sclerosis)? (1)

Answer 147

Perpendicularly orientated with long axis of the lateral ventricles

Question 148

What areas of the brain could be responsible for gait ataxia? (4)

Answer 148

1. Cerebellum + its connections (cerebellar ataxia) 2. Dorsal columns of spinal cord (sensory ataxia) 3. Peripheral nerves/nerve roots (sensory ataxia) 4. Vestibular apparatus + connections

Question 149

What is L'Hermitte's Phenomenon? (2)

Answer 149

1. Tingling sensations upon flexion + extension of the neck that radiates down spine 2. Common sign in multiple sclerosis

Question 150

Where are the most important locations for a multiple sclerosis lesion? (4)

Answer 150

1. Corpus Callosum 2. Juxta-cortical 3. Brainstem (including cerebellum) 4. Spinal cord

Question 151

When can a diagnosis of Multiple Sclerosis be made? (1)

Answer 151

1. 2 separate clinical attacks of inflammation within the CNS at different times and in different places

Question 152

How is a multiple sclerosis relapse treated? (1)

Answer 152

High dose steroids

Question 153

What are the potential risks of giving high dose steroids? (7)

Answer 153

1. GI upset (use PPI cover) 2. Agitation 3. Restlessness 4. Insomnia 5. Frank behavioural disturbance (steroid psychosis) 6. Hyperglycemia 7. Avascular necrosis of hip (rare)

Question 154

What is the first-line treatment of relapse in multiple sclerosis? (2)

Answer 154

1. Methylprednisolone (PO, 500mg once daily for 5 days) - outpatient! 2. Methylprednisolone (IV, 1g once daily for 3 days) - hospital admission required!

Question 155

What is the criteria for being eligible for multiple sclerosis 'disease-modifying treatment'? (1)

Answer 155

Patients experiencing 2+ significant relapses over a 2-year period

Question 156

What blood test is very important in a patient presenting with a dorsal cord syndrome? (1)

Answer 156

Serum B12 levels

Question 157

What (blood) tests are done before giving high dose steroids? (5)

Answer 157

1. Symptoms of infection 2. FBC 3. Renal function 4. Random glucose 5. Urine dipstick (looking for signs of UTI)

Question 158

What can an injection of Gadolinium contrast material on CT head indicate?

Answer 158

Areas of blood-brain barrier breakdown due to active/recent inflammation

Question 159

Name a disease-modifying drug used in multiple sclerosis?

Answer 159

Betaferon (beta-interferon 1b)

Question 160

Name 4 commonly used drugs to aid in symptomatic treatment of complications of multiple sclerosis

Answer 160

1. Baclofen (for spasticity/increased tone) 2. Gabapentin (for neuropathic pain) 3. Sertraline (for depression) 4. Oxybutinin (anticholinergic drug for neuropathic bladder)

Question 161

What are the possible treatments for neuropathic pain? (5)

Answer 161

1. Anticonvulsants (pregabalin, gabapentin) 2. Tricyclic antidepressants (amitryptiline, nortriptyline) 3. Carbamazapine, oxcarbazepine (if neuropathic pain of face related to trigeminal nerve) 4. Selective serotonin + norepinephrine re-uptake inhibitors (duloxetine) 5. Others (Capsaicin cream, Lidocaine patches, nerve blocks, epidural injections, surgical options)

Question 162

What is multiple sclerosis?

Answer 162

Chronic autoimmune disease of the central nervous system (brain + spinal cord) causing demyelination

Question 163

How does multiple sclerosis manifest?

Answer 163

1. Optic neuritis (pain on eye movement, blurring vision, red colour saturation) 2. Cerebral (fatigue, weakness, sensory disturbances) 3. Brainstem symptoms (vertigo, slurred speech, incoordination, double vision) 4. Spinal cord (weakness, sensory disturbance, autonomic dysfunction)

Question 164

What are the different types of multiple sclerosis? (4)

Answer 164

1. Relapsing-Remitting MS (most common) 2. Secondary Progressive MS (initially relapsing followed by progressive disease with/without relapses) 3. Primary Progressive MS (progression from onset. no attacks) 4. Progressive-Relapsing MS (progression from onset with attacks)

Question 165

What are the 3 types of multiple sclerosis lesions?

Answer 165

1. Acute active plaques (in relapsing-remitting MS) 2. Chronic active plaques (more in progressive MS) 3. Chronic inactive plaques (in progressive MS)

Question 166

What investigations are performed for multiple sclerosis? (3)

Answer 166

1. MRI head 2. CSF analysis 3. Evoked potentials (how fast signals reach occipital cortex/dorsal columns)

Question 167

What are the CSF results for a patient with multiple sclerosis? (4)

Answer 167

1. Low WCC (<50 x 10^6/ml) 2. Low protein (<1g/ml) 3. High CSF/serum glucose ratio (>0.4) 4. Oligoclonal bands present in CSF (absent in serum)

Question 168

What is the pathophysiological meaning of oligoclonal bands being present in the CSF?

Answer 168

A production of immunoglobulins in the CNS meaning its a primary CNS disease (multiple sclerosis)

Question 169

What are 4 examples of injectable disease-modifying treatments for multiple sclerosis?

Answer 169

1. Beta interferon (IM/SC) 2. Glatiramer acetate (SC) 3. Alemtuzumab (IV) 4. Natalizumab (IV)

Question 170

What are 3 examples of oral disease-modifying treatments for multiple sclerosis?

Answer 170

1. Dimethyl fumerate 2. Teriflunomide 3. Fingolimod

Question 171

What is the mechanism of action of high dose steroids in treating a multiple sclerosis relapse? (2)

Answer 171

1. Reduces inflammatory activity | 2. Stabilizes the BBB

Question 172

What is the mechanism of action of interferons used in multiple sclerosis? (1)

Answer 172

Interferes with T cell migration across the BBB

Question 173

What is the mechanism of action of Teriflunomide in the treatment of multiple sclerosis? (1)

Answer 173

Anti-proliferative action

Question 174

What is the mechanism of action of Glatiramer in the treatment of multiple sclerosis? (1)

Answer 174

Desensitising the immune system from myelin

Question 175

What is the mechanism of action of Dimethyl Fumerate in the treatment of multiple sclerosis? (1)

Answer 175

Proinflammatory cytokine inhibitor

Question 176

What is the mechanism of action of Fingolimod in the treatment of multiple sclerosis? (1)

Answer 176

Inhibits the migration of T cells from lymphoid tissue into blood by blocking S1P receptors

Question 177

What is the mechanism of action of Alemtuzumab in the treatment of multiple sclerosis? (1)

Answer 177

Monoclonal targets B and T cells resulting in cell lysis

Question 178

What is the mechanism of action of Natalizumab in the treatment of multiple sclerosis? (1)

Answer 178

Prevents lymphocyte migration across the BBB

Question 179

What complications are associated with Alemtuzumab use (in multiple sclerosis)? (4)

Answer 179

1. Antibody mediated autoimmune diseases 2. Thyroid disease 3. Immune thrombocytopenia 4. Goodpasture syndrome

Question 180

What complications are associated with Natalizumab use (in multiple sclerosis)? (1)

Answer 180

1. Progressive multifocal leukoencephalopathy | - Caused by JC virus (John Cunningham virus)

Question 181

What is a common MS relapsing symptom? (1)

Answer 181

1. Urinary symptoms: frequency, urgency, retention

Question 182

What is Devic's syndrome (neuromyelitis optica)? (3)

Answer 182

1. Inflammatory disease of the CNS 2. Longitudinally extensive transverse myelitis (inflammation spanning more than 3 vertebrae) 3. Optic neuritis 4. NMO antibodies or aquaporin 4 antibodies present

Question 183

Name 3 conditions that present like multiple sclerosis except they have more systemic symptoms

Answer 183

1. Anticardiolipin antibody syndrome 2. Neurosarcoidosis 3. Sjogren's syndrome

Question 184

What structure is responsible for coloured vision + fine detail? (1)

Answer 184

Fovea

Question 185

What structure is responsible for central visual acuity? (1)

Answer 185

Macula

Question 186

When assessing the optic disc, what should you comment on? (3)

Answer 186

"3 Cs" 1. Cup (cup to disc ratio) 2. Colour (i.e. "pink healthy colour"/pale = nerve death) 3. Contour (i.e. blurred/well-defined)

Question 187

What is a normal healthy cup to disc ratio? (1)

Answer 187

0.3

Question 188

What are the ocular muscles? (6)

Answer 188

1. Inferior oblique 2. Superior oblique (CN4) 3. Medial rectus 4. Lateral rectus (CN6) 5. Superior rectus 6. Inferior rectus

Question 189

What questions would you ask in an ophthalmology history pertaining to the presenting complaint? (6)

Answer 189

1. Pain 2. Loss of vision 3. Trauma 4. Discharge 5. Redness 6. Photophobia

Question 190

What questions need to be asked in the past ophthalmic history portion of an ophthalmology history? (3)

Answer 190

1. Previous surgery 2. Short/long sighted 3. Contact lenses

Question 191

What are 3 common ophthalmologic conditions that run in the family?

Answer 191

1. Glaucoma 2. Dystrophy 3. Blindness

Question 192

List 3 drugs that can affect vision?

Answer 192

1. Anti-TB 2. Amiodarone 3. Chloroquine

Question 193

Name 4 medical conditions that can have ophthalmic manifestations?

Answer 193

1. Diabetes 2. Hypertension 3. RA 4. Sarcoid

Question 194

What does it mean to have myopic vision? (5)

Answer 194

1. Short-sighted 2. Large globe 3. Problems with distance 4. Glasses minify images 5. Risk of retinal detachment 6. Concave lens

Question 195

What does it mean to have hypermetropic vision? (5)

Answer 195

1. Long-sighted 2. Small globe 3. Problems with near vision 4. Glasses magnify 5. Risk of acute glaucoma 6. Convex lens

Question 196

What does it mean to have 6/6 vision?

Answer 196

Normal vision. A patient can see at 6m away from the chart what we would expect them to see at that distance.

Question 197

If a patient cannot read the Snellen Chart, what other ways are there to test visual acuity? (3)

Answer 197

1. Count fingers 2. Hand movements 3. Light Perception (if none = No perception of light (NPL)

Question 198

Name 2 ways to test visual acuity in babies

Answer 198

1. Preferential looking | 2. Kay picture cards

Question 199

Name 5 ocular emergencies

Answer 199

1. Giant cell arteritis -> life threatening 2. Central retinal artery occlusion (CRAO) -> sudden loss of vision 3. Orbital cellulitis -> life threatening 4. Retinal detachment 5. Acute angle closure glaucoma

Question 200

What is the most concerning cause of a white pupil (leukocoria) in a child?

Answer 200

Retinoblastoma

Question 201

What is the most common cause of glaucoma? (1)

Answer 201

Raised intraocular pressure

Question 202

How is glaucoma monitored? (1)

Answer 202

Assessing visual fields

Question 203

How can we determine whether a visual problem is due to refractory error or the eye itself? (1)

Answer 203

Read Snellen chart again with Pin Holes

Question 204

How is visual acuity recorded in medical notes? (1)

Answer 204

Distance from the chart/number of the lowest line read

Question 205

If the patients vision was 6/12 with corrected lenses what should be your next course of action?

Answer 205

Retest with pin holes (record with PH in front of VA number) ** Always retest if patient doesn't achieve 6/6 to exclude refractory error**

Question 206

What does visual acuity rely on? (3)

Answer 206

1. How accurately light is focused on the retina (mostly macula region) 2. Integrity of the eye's neural elements 3. Interpretative faculty of the brain

Question 207

What are the photoreceptors in the retina called? (2)

Answer 207

1. Rods | 2. Cones

Question 208

What are rods (photoreceptors in retina) responsible for? (1)

Answer 208

1. Night vision

Question 209

What are cones (photoreceptors in retina) responsible for? (2)

Answer 209

1. Colour | 2. Daylight vision

Question 210

What is the difference in collagen fibre arrangement between the cornea and the sclera? (1)

Answer 210

Regular (in cornea) vs irregular (in sclera) arrangement of collagen fibres

Question 211

What 2 questions are important to always ask in ophthalmic history?

Answer 211

1. Has your vision been affected? | 2. Are your eyes uncomfortable at all?

Question 212

What is the differential for a gritty/dry eyes that feel tired? (1)

Answer 212

Dry eye

Question 213

Where is the problem for a sharp/stabbing pain "like needles" in the eye? (1)

Answer 213

Ocular surface problem

Question 214

What is the differential for a dull ache (like toothache) in the eye? (3)

Answer 214

1. Uveitis 2. Raised intraocular pressure 3. Scleritis

Question 215

Where is the pathology if there is total blindness in 1 eye?

Answer 215

Optic nerve lesion

Question 216

Where is the pathology in bipolar hemianopia?

Answer 216

Optic chiasm lesion

Question 217

Where is the pathology in R nasal hemianopia?

Answer 217

R perichiasmic area lesion

Question 218

Where is the pathology in L homonymous hemianopia?

Answer 218

Lesion or pressure on R optic tract

Question 219

Where is the pathology in L homonymous inferior quadrantanopia?

Answer 219

Lower right optic radiations lesion

Question 220

Where is the pathology in L homonymous superior quadrantanopia?

Answer 220

Upper right optic radiations lesion

Question 221

Where is the pathology in L homonymous hemianopia?

Answer 221

R occipital lobe lesion

Question 222

What medication is typically used to dilate the pupil? (1)

Answer 222

1% Tropicamide

Question 223

When performing fundoscopy, why do we ask patients to look directly into the light? (1)

Answer 223

To bring the macula into direct view.

Question 224

What does an increased cup to disc ratio indicate?

Answer 224

Decrease in the quantity of healthy neuroretinal tissue (glaucomatous changes)

Question 225

What 3 structures can be examined with a direct ophthalmoscope?

Answer 225

1. Retina 2. Pupils 3. Iris

Question 226

What is the pathophysiology of dry macular degeneration? (1)

Answer 226

1. Progresses slowly as extensive wasting of macula cells occurs

Question 227

What is the pathophysiology of wet macular degeneration? (1)

Answer 227

1. New blood vessels develop beneath and within the retina and can lead to a rapid deterioration of vision

Question 228

What are risk factors for glaucoma? (9)

Answer 228

1. Raised intraocular pressure 2. Age 3. Family history 4. Ethnicity 5. Corticosteroid use 6. Myopia 7. Type 2 diabetes 8. Cardiovascular disease 9. Hypertension

Question 229

What are signs of acute closed angle glaucoma? (6)

Answer 229

1. Severe headache 2. Eye pain 3. N/V 4. Blurred vision 5. Halos around lights 6. Eye redness

Question 230

What drug classes are used in pupil dilating drops? (2)

Answer 230

1. Antimuscarinics (atropine is contraindicated) | 2. Alpha-adrenergic agonist

Question 231

List 4 ocular causes of pupil abnormality?

Answer 231

1. Anterior uveitis (due to posterior adhesions) 2. Sequelae of intraocular surgery 3. Blunt trauma to the eye (may rupture sphincter muscle = fixed dilation/irregularity) 4. Acute glaucoma (increased ocular pressure)

Question 232

What are the 4 characteristics of Horner's Syndrome?

Answer 232

1. Miosis 2. Ptosis 3. Anhydrosis 4. Enophthalmos

Question 233

Name 4 other conditions that can present with Horner's Syndrome?

Answer 233

1. Syringomyelia 2. Small-cell carcinoma 3. Neck injury/disease/surgery 4. Cavernous sinus disease

Question 234

What are the features of Adie's pupil? (3)

Answer 234

1. Enlarged 2. Poorly reactive to light 3. Slow, sustained miosis on accommodation

Question 235

What is the diagnostic test for Adie's pupil? (1)

Answer 235

Constricts to dilute pilocarpine (0.1%) unlike the normal pupil

Question 236

What are the features of Argyll-Robertson pupil? (3)

Answer 236

1. Pupils are bilaterally small + irregular 2. No response to light but respond to accommodation 3. Classically seen in neurosyphilis

Question 237

What finding on fundoscopy is typically seen in age-related macular degeneration? (2)

Answer 237

1. Presence of drusen (yellowish-coloured sub retinal lesions) -> DRY macular degeneration 2. Hemorrhage + fluid buildup associated with sub-retinal membrane -> WET macular degeneration

Question 238

What are risk factors for dry macular degeneration? (4)

Answer 238

1. Female 2. Smoking 3. Hypertension 4. Previous cataract surgery

Question 239

What are symptoms of dry macular degeneration?

Answer 239

1. Gradual loss of central vision 2. Difficulty reading + seeing fine detail 3. Cannot see people's faces clearly 4. Peripheral vision spared

Question 240

What is the commonest cause of irreversible vision loss in the developed world?

Answer 240

Age-related macular degeneration

Question 241

What treatment is available for wet AMD (age-related macular degeneration)? (1)

Answer 241

Anti-vascular endothelial growth factor (anti-VEGF) drug injections - Inhibit VEGF and prevent neovascularisation in wet AMD **No treatment available for dry AMD**

Question 242

Where does the optic disc lie when visualizing it in fundoscopy?

Answer 242

In the nasal part of the fundus

Question 243

What are the signs of primary open angle glaucoma? (4)

Answer 243

1. Raised intraocular pressure 2. Painless 3. Cupping of the optic disc (optic nerve damage) 4. Visual field defect (loss of vision)

Question 244

What is the most common type of glaucoma?

Answer 244

Primary open angle glaucoma

Question 245

What are the risk factors for glaucoma? (6)

Answer 245

1. Being short-sighted 2. Having a thin cornea 3. Old age 4. Diabetes 5. Race 6. Family history

Question 246

What is the normal intraocular pressure range?

Answer 246

10-20mmHg

Question 247

What is a Goldmann Tonometer used for?

Answer 247

Measuring intraocular pressure

Question 248

Name 4 medications that lower intraocular pressure?

Answer 248

1. Pilocarpine 2. Steroids 3. B-blockers 4. Carbonic anhydrase inhibitors

Question 249

What DVLA vision standards must be met in order to drive a car? (3)

Answer 249

1. Read (with glasses/contacts) a car license plate from 20m 2. Visual acuity of at least 6/12 on Snellen chart 3. Adequate field of vision

Question 250

Where is the optic nerve located in the eye and what is its significance in vision? (2)

Answer 250

1. Located on the temporal side of the field | 2. It is the blind spot (no photoreceptors)

Question 251

What is a normal visual field? (3)

Answer 251

1. 90º temporally to central fixation 2. 50º superiorly and nasally 3. 60º inferiorly

Question 252

What test is used to diagnose AMD (age-related macular degeneration)?

Answer 252

Amsler grid

Question 253

What are 5 risk factors for acute angle closed glaucoma?

Answer 253

1. Female 2. Near-sighted 3. History of vomiting 4. Progressive headache 5. Blurred vision

Question 254

What are the components of the trabecular meshwork that is responsible for aqueous drainage of the eye? (5)

Answer 254

1. Uveal meshwork (at anterior chamber side) 2. Corneo-scleral meshwork 3. Endothelial meshwork 4. Schlemm's canal 5. Sclera with collector channel

Question 255

What is the treatment for acute angle closed glaucoma? (1)

Answer 255

Peripheral iridotomy (and always treat the unaffected eye, prophylactically)

Question 256

What occurs to the eye in acute angle closure glaucoma? (1)

Answer 256

Anterior chamber is pushed forward/shallow = positive pen torch test

Question 257

Name 2 drugs that can cause a narrowing of the drainage angle in the eye (thus increasing the risk of acute angle closed glaucoma)

Answer 257

1. Tropicamide | 2. Phenylephrine

Question 258

What is the most likely diagnosis for a cherry red spot seen on fundoscopy? (1)

Answer 258

Central retinal artery occlusion

Question 259

Name the 10 layers of the retina, from outermost to innermost

Answer 259

1. Retinal pigment epithelium 2. Photoreceptor layer 3. External limiting membrane 4. Outer nuclear layer 5. Outer plexiform layer 6. Inner nuclear layer 7. Inner plexiform layer 8. Ganglion cell layer 9. Nerve fibre layer 10. Internal limiting membrane

Question 260

Where is the thinnest part of the retina?

Answer 260

At the fovea

Question 261

What underlying medical condition must be excluded when dealing with central retinal artery occlusion? (1)

Answer 261

Giant temporal arteritis

Question 262

What are the risk factors for central retinal artery occlusion? (7)

Answer 262

1. Raised cholesterol 2. Hypertension 3. Atherosclerosis 4. Diabetes 5. Associated vascular problems (TIA, angina) 6. Family history of vascular problems 7. Smoking

Question 263

Name 2 risk factors for retinal detachment

Answer 263

1. Trauma (high velocity vitreous movement = traction on retina) 2. Myopia (larger eyeballs = thinner retina at far periphery = increased chance of retinal tears)

Question 264

What is the differential diagnosis for a myopic patient with sudden onset of floaters and shadow, with no pain, and no change in visual acuity? (1)

Answer 264

Retinal detachment

Question 265

What is the differential diagnosis for acute painless loss of vision? (1)

Answer 265

Central retinal artery occlusion

Question 266

What is the treatment for retinal detachment? (1)

Answer 266

Vitrectomy

Question 267

What are 5 possible causative agents of orbital cellulitis?

Answer 267

1. Staph. aureus 2. Strep. pneumonia 3. H. influenza 4. Betahemolytic streptococcus 5. Aspergillus (if severely immunocompromised)

Question 268

What is the pathophysiology of orbital cellulitis?

Answer 268

Infection often arises from an adjacent ethmoid sinus, reflecting that the medial wall of the orbit is extremely thin

Question 269

Why is orbital cellulitis an ophthalmological emergency? (1)

Answer 269

Can spread to cause a brain abscess

Question 270

What are the presenting features of orbital cellulitis? (6)

Answer 270

1. A painful, proptosed eye 2. Conjuctivial injection 3. Periorbital inflammation/swelling 4. Reduced eye movements 5. Possible visual loss 6. Systemic illness + pyrexia

Question 271

What investigations are essential for diagnosing orbital cellulitis? (4)

Answer 271

1. Orbital scan (MRI/CT) 2. FBC 3. Blood cultures 4. Swab from the conjunctivae

Question 272

How is orbital cellulitis treated? (2)

Answer 272

1. IV broad-spectrum antibiotics | 2. Orbital decompression

Question 273

What bedside tests must be done hourly in orbital cellulitis? (4)

Answer 273

1. Temperature 2. Pulse 3. Visual acuity 4. Blood pressure

Question 274

What is a hypopyon?

Answer 274

Accumulation of WBC in the anterior chamber of the eye

Question 275

What are the risk factors for infective Endophthalmitis? (3)

Answer 275

1. Recent ocular surgery 2. Septicemia 3. Long lines and in-dwelling catheters/tubes

Question 276

What are the presenting features for infective Endophthalmitis? (4)

Answer 276

1. Red eye 2. Hypopyon 3. Painful 4. Reduced vision

Question 277

How is infective Endophthalmitis managed? (2)

Answer 277

1. Immediate sampling of intraocular fluid (vitreous tap) | 2. Intravitreal injection of antibiotics

Question 278

What is the pathophysiology of acute angle closure glaucoma? (1)

Answer 278

Aqueous humour cannot be drained due to a blocked iridocorneal angle, leading to an increase in intraocular pressure

Question 279

What are the causes of acute angle closure glaucoma? (2)

Answer 279

1. Primary causes (anatomical - anterior/posterior forces) | 2. Secondary causes (blockage of the trabecular meshwork)

Question 280

What does gonioscopy look at? (1)

Answer 280

Looks for closed iridocorneal angles in acute angle closure glaucoma

Question 281

What is the management for patients with acute angle closure glaucoma? (3)

Answer 281

1. Eye drops - Timolol - Apradonidine - Prednisolone - Pilocarpine 2. IV acetazolamide ± mannitol 3. Peripheral iridotomy (once IOP has normalized)

Question 282

What are 4 eye drops that can be used in the treatment of acute angle closure glaucoma?

Answer 282

1. Timolol 2. Apradonidine 3. Prednisolone 4. Pilocarpine

Question 283

What is the classical triad presentation of acute angle closure glaucoma (seen often in exam questions!)? (6)

Answer 283

1. Severe eye pain 2. Haloes around lights 3. Decreased visual acuity (4. Non-reactive pupil) (5. Ciliary flush) (6. Raised intraocular pressure)

Question 284

Name 5 conditions which are ocular emergencies

Answer 284

1. Acute angle closure glaucoma 2. Retinal detachment 3. Orbital cellulitis 4. Central retinal artery occlusion 5. Infective endopthalmitis

Question 285

Name 4 drug classes used in relieving an attack of acute angle closure glaucoma

Answer 285

1. B-blockers (Timolol) 2. Carbonic anhydrase inhibitors (acetazolamide) 3. Steroids (Prednisolone) 4. Pilocarpine

Question 286

Why does the cornea become cloudy in an attack of acute angle closure glaucoma?

Answer 286

It becomes 'waterlogged' due to the raised intraocular pressure

Question 287

What are 4 signs that point to a diagnosis of conjunctivitis?

Answer 287

1. Reactive pupils 2. Conjunctival injection (red eye) 3. Normal visual acuity 4. Mucoid discharge

Question 288

What investigations would you do for conjunctivitis? (4)

Answer 288

1. Viral swabs 2. Chlamydial swabs 3. Bacterial swabs 4. PCR (polymerase chain reaction)

Question 289

What eye drop would help investigate red eye symptoms? (1)

Answer 289

Fluorescein - visualized using a cobolt-blue filter - doesn't stain intact corneal epithelium but does stain the deeper corneal stroma - highlights areas of epithelial loss

Question 290

What is a hyphema? (2)

Answer 290

1. Pooling of blood inside the anterior chamber of the eye | 2. Usually painful

Question 291

What is a dendritic ulcer?

Answer 291

1. Ulcer or inflammation on the cornea | 2. Caused by Herpes Simplex Virus

Question 292

What treatment is used for herpes simplex infection? (1)

Answer 292

Topical aciclovir ointment for the eye ± cream for skin lesions

Question 293

What is uveitis? (2)

Answer 293

1. Inflammation of the uveal tract which involves the iris, ciliary body, retina and choroid 2. Presents with blurred vision, no discharge, sore eye

Question 294

What is anterior uveitis?

Answer 294

Inflammation of the iris

Question 295

What are the signs of anterior uveitis? (3)

Answer 295

1. Intra-ocular inflammation 2. Cells in anterior chamber + posterior synechiae (hypopyon) 3. Posterior synechiae (iris adheres to lens)

Question 296

What are the complications associated with posterior synechiae? (2)

Answer 296

1. Irregular pupil | 2. Raised intraocular pressure

Question 297

What is the pathophysiology of acute bacterial conjunctivitis?

Answer 297

Common + self-limiting condition that is caused by direct eye contact with infected secretions

Question 298

What organisms are responsible for bacterial conjunctivitis? (6)

Answer 298

1. S. pneumoniae 2. S. aureus 3. H. influenzae 4. Moraxella catarrhalis 5. Neisseria gonorrhoea (rare) 6. Neisseria meningitidis (rare - affects kids)

Question 299

What 3 agents are used in the management of bacterial conjunctivitis?

Answer 299

1. Chloramphenicol eye drops 2. Topical lubricants 3. Cool compress

Question 300

What antibiotic would be used to treat a gonococcal infection causing conjunctivitis? (3)

Answer 300

1. Ceftriaxone (3rd generation cephalosporin) 2. Quinolones 3. Macrolides

Question 301

What antibiotic is used to treat H. influenzae conjunctival infection? (2)

Answer 301

Oral amoxicillin + clavulanic acid

Question 302

What antibiotic is used to treat meningicoccal conjunctivitis? (3)

Answer 302

1. IM benzylpenicilllin 2. Ceftriaxone/cefotaxime 3. Oral ciprofloxacin

Question 303

What is the most frequent causative agent of viral conjunctivitis? (1)

Answer 303

Adenovirus

Question 304

What ulcer is associated with contact lens wear?

Answer 304

Bacterial corneal ulcer (microbial keratitis)

Question 305

What 3 things are contraindicated in bacterial keratitis?

Answer 305

1. Oral antibioitics 2. Contact lens wear 3. Steroid eye drops

Question 306

What is a complication if bacterial keratitis is left untreated?

Answer 306

Corneal perforation

Question 307

What is the first line treatment for red eye caused by bacterial conjunctivitis? (1)

Answer 307

Chloramphenicol eye drops

Question 308

What are 4 tips for junior doctors when assessing a patient with red eye?

Answer 308

1. Always ask about vision loss + check visual acuity 2. Always stain the surface with fluorescein to assess for corneal pathology 3. Have high index for suspicion for diagnoses of anterior uveitis + acute angle closure glaucoma 4. Review patients to check if symptoms have improved with treatment

Question 309

What is not included in the management of severe contact lens related keratitis?

Answer 309

Frequent chloramphenicol drops **pseudomonas aeruginosa is most frequent bacteria associated with contact lens wear + is not sensitive to chloramphenicol**

Question 310

A 14 year old comes to the casualty clinic with unilateral red eyes, watery and very itchy. His older sister also had a similar problem 1 week ago. On examination, you notice that his pre-auricular lymph-nodes and swollen. What are your thoughts? (3)

Answer 310

1. Viral conjunctivitis | 2. eyelid hygiene + eye lubrication

Question 311

What symptoms differentiates corneal disease from conjunctivitis? (2)

Answer 311

1. Pain | 2. Photophobia

Question 312

What discharge is associated with bacterial conjunctivitis? Viral conjunctivitis? (2)

Answer 312

1. Purulent discharge = bacterial conjunctivitis | 2. Watery discharge = viral conjunctivitis

Question 313

What are the signs of conjunctival disease? (4)

Answer 313

1. Papillae 2. Follicles 3. Dilation of conjunctival vasculature (injection) 4. Subconjunctival hemorrhage

Question 314

What is the cause of follicles in the eye? (2)

Answer 314

1. Viral infections | 2. Chlamydial infections

Question 315

What are the signs of corneal disease? (5)

Answer 315

1. Epithelial + stromal oedema (clouding of cornea) 2. Cellular infiltrate in stroma causing focal, granular white spots 3. Deposits of cells on corneal endothelium (keratic precipitates) 4. Pannus (growth of blood vessels into peripheral cornea) 5. Punctate Epithelial Erosions (PEE) - points of superficial epithelial loss

Question 316

What are the 3 features of bacterial conjunctivitis?

Answer 316

1. Red eye 2. Discharge 3. Ocular irritation

Question 317

What is the term for conjunctivitis that occurs within the first 28 days after birth, and is a notifiable disease?

Answer 317

Ophthalmia neonatorum

Question 318

What are the common causative organisms for opthalmia neonatorum? (4)

Answer 318

1. Bacterial conjunctivitis (usually gram-positive) 2. Neisseria gonorrhoea 3. Herpes Simplex 4. Chlamydia

Question 319

What are the 3 features of viral conjunctivitis?

Answer 319

1. Watery and limited purulent discharge 2. Conjunctival follicles + Preauricular lymph node enlargement 3. Lid oedema + excessive lacrimation

Question 320

What is the commonest infective cause of blindness in the world? (1)

Answer 320

Trachoma (chlamydial infection)

Question 321

What are the signs and symptoms of corneal infection? (4)

Answer 321

1. Pain 2. Purulent discharge 3. Ciliary injection 4. Visual loss 5. Hypopyon 6. White corneal opacity often seen with naked eye

Question 322

What are 3 signs of corneal graft rejection?

Answer 322

1. Redness 2. Pain 3. Visual loss

Question 323

What is the treatment for corneal graft rejection? (1)

Answer 323

Intensive topical steroid

Question 324

What 3 conditions is scleritis associated with?

Answer 324

1. Rheumatoid arthritis 2. Polyarteritis nodosum 3. SLE

Question 325

What is the treatment for scleritis? (2)

Answer 325

1. High dose steroids | 2. Cytotoxic agents (in severe cases)

Question 326

What abnormality will be observed with a 6th nerve palsy (lateral rectus palsy)? (1)

Answer 326

Failure to abduct affected eye

Question 327

What are the causes of a 6th nerve palsy? (5)

Answer 327

1. Microvascular Infarct - poor blood supply to CN6 (HTN, diabetes, hypercholesteremia, smoking) 2. Tumours, middle ear infection, swelling of neighbouring blood vessels 3. Raised ICP 4. Head injury (due to raised ICP) 5. Inflammation to region of the 6th nerve

Question 328

What are the typical features of lateral rectus palsy? (3)

Answer 328

1. Sudden onset of horizontal double vision (worse when looking to affected side) 2. Limitated abduction on affected side 3. Convergent squint (when looking at an object far away)

Question 329

How can convergent squints due to lateral rectus palsy's be treated? (2)

Answer 329

1. Glasses with fresnel prisms | 2. Botox into medial rectal muscle

Question 330

What sign on fundoscopy indicates high intracranial pressure? (1)

Answer 330

Bilateral swollen optic discs (papilloedema) **Urgent neuroimaging needed to rule out compression lesion!**

Question 331

What are the causes of a third nerve palsy? (5)

Answer 331

1. Microvascular problems (HTN, smoking, diabetes, high cholesterol) 2. Aneurysms 3. Tumour/direct pressure 4. Head injuries 5. Inflammation in region of the 3rd nerve (ophthalmoplegic migraine)

Question 332

What are the typical features of a 3rd nerve palsy? (4)

Answer 332

1. Sudden onset of droopy eyelid (ptosis) 2. Horizontal + vertical double vision 3. Eye deviated 'down and out' 4. Pupil on affected side is dilated (indicates cause likely due to aneurysm rather than microvascular problem)

Question 333

Why is a 3rd nerve palsy considered a medical emergency? (1)

Answer 333

Risk of it being caused by a posterior communicating artery/internal carotid artery aneurysm (esp. if pupil is dilated + painful + doesn't react to light)

Question 334

What eye muscles are not innervated by CN3? (2)

Answer 334

1. Lateral rectus (CN6) | 2. Superior oblique (CN4)

Question 335

What is the pathophysiology of a blow-out facial fracture?

Answer 335

Inferior orbital floor fracture due to trauma and the resulting increase in intracranial pressure from within the orbit

Question 336

What eye gaze abnormalities result from a blow-out facial fracture? (1)

Answer 336

Vertical gaze diplopia

Question 337

What clinical sign can be elicited in a blow-out facial fracture?

Answer 337

Infra-orbital paraesthesia -b/c V2 division of the trigeminial nerve may be affected meaning sensation is lost below the orbit

Question 338

Name 4 investigations required for diagnosing myasthenia gravis

Answer 338

1. Acetylcholine receptor antibodies 2. Neurophysiology with repetitive stimulation ± single fibre studies 3. CT/MRI brain (rule out mass/lesion compression) 4. CT thorax (rule out mass/lesion compression)

Question 339

What are the causes of a 4th nerve palsy? (3)

Answer 339

1. Vasculopathic (HTN, diabetes) 2. Tumour 3. Congenital 4. Trauma

Question 340

What are the features of a 4th nerve palsy? (2)

Answer 340

1. 'Nasal upshoot' | 2. Head tilt away from affected side (esp in congenital cases)

Question 341

What are risk factors for papilloedema? (3)

Answer 341

1. Young women 2. Antibiotic use 3. Recent weight gain

Question 342

What DVLA requirements must be met in someone with a history of diplopia? (3)

Answer 342

1. Patients can return to driving a car after diplopia has resolved/period of adaptation (i.e. prisms, eye patch) 2. Other eye must have sufficient vision (i.e. 6/12) and adequate visual fields 3. Drivers of lorries/trucks (Group 2 license) cannot drive with persistent diplopia, even after adaptation

Question 343

A patient came to the Emergency Eye Clinic with sudden onset diplopia for a week. The patient had high levels of Acetylcholine Receptor antibodies and was diagnosed with Myastenia Gravis. What further investigation does the patient need? (1)

Answer 343

A chest CT (looking for compression causing lesion)

Question 344

A 40 year old lady comes to the Eye Casualty Clinic complaining of diplopia and headaches for 2 weeks. She also tells you that she is being treated by her GP for otitis for the last 6 weeks with various topical and oral antibiotics. What are you most worried about? (1)

Answer 344

Cavernous sinus thrombosis

Question 345

What are the features of cavernous sinus thrombosis? (4)

Answer 345

1. Severe headache around eyes 2. Swelling/bulging of eyes 3. Eye pain 4. Double vision (6th nerve palsy)

Question 346

How can a lateral rectus palsy be treated? (1)

Answer 346

Cover the affected eye

Question 347

What is the clinical significance of leukocoria? (3)

Answer 347

1. White pupil 2. Means the red reflex has been lost 3. There is an opacity in the optical media of the eye

Question 348

What cause of leukocoria should be excluded immediately? (1)

Answer 348

Retinoblastoma

Question 349

What are possible differentials for leukocoria? (7)

Answer 349

'PREDICT' P-persistent hyperplastic primary virtreous R-retinoblastoma/retinopathy of prematurity E-endopthalmitis D-dysplasia of the retina I-inflammatory cyclitic membrane C-congenital cataract/Coat's Disease T-toxocariasis

Question 350

Which dilating eye drops are used in children? (1)

Answer 350

Cyclopentolate

Question 351

What are risk factors of retinopathy of prematurity? (2)

Answer 351

1. Premature infants with very low birthweight | 2. Exposure to high ambient oxygen concentrations

Question 352

What is the treatment of choice for retinopathy of prematurity? (1)

Answer 352

Laser photocoagulation

Question 353

What is the pathophysiology of retinopathy of prematurity? (2)

Answer 353

1. Premature birth + oxygen down-regulates the production of VEGF, halting blood vessel formation 2. Subsequent increased metabolic demand from the growing eye allows excessive VEGF production leading to the neovascular complications of ROP

Question 354

At what age should babies be screened for ROP? (1)

Answer 354

4-7 weeks postnatally (if they have been born ≤31 weeks or weighing ≤ 1500g)

Question 355

Name 2 sight-threatening complications that can result from untreated retinopathy of prematurity?

Answer 355

1. Retinal detachment | 2. Vitreous hemorrhage

Question 356

What gene predisposes to retinoblastoma? (1)

Answer 356

RB1 13q14

Question 357

What are the 2 categories of retinoblastoma?

Answer 357

1. Heritable (germline) retinoblastoma (40%) | 2. Non-heritable retinoblastoma (60%)

Question 358

What are the treatment options for retinoblastoma? (4)

Answer 358

1. Chemotherapy 2. Radiotherapy 3. Brachytherapy 4. Enucleation (removing the eyeball)

Question 359

How can congenital cataracts be categorized? (2)

Answer 359

1. Genetic mutation = bilateral congenital cataracts | 2. Sporadic mutation = unilateral congenital cataract

Question 360

Name 4 types of congenital cataracts

Answer 360

1. Lamellar cataract (uniform cloudiness) 2. Sutural cataract (Y formation) 3. Nuclear cataract (small central area of cloudiness ± white-dot like opacities) 4. Blue Dot cataract (discrete punctuate blue opacities throughout cortex)

Question 361

Which 5 diseases/infections are associated congenital cataracts?

Answer 361

1. Cytomegalovirus 2. Varicella 3. Rubella 4. Down Syndrome (trisomy 21) 5. Edward Syndrome (trisomy 18; typically die young)

Question 362

What treatment, at what age, is required for bilateral dense cataracts? (1)

Answer 362

1. Early surgery when child is 4-6 weeks of age to prevent amblyopia

Question 363

What treatment is required for bilateral partial cataracts? (1)

Answer 363

1. May not require surgery until later if at all

Question 364

What treatment is required for unilateral dense cataract? (3)

Answer 364

1. Urgent surgery (within days) 2. Aggressive anti-amblyopia therapy (i.e. eye patch, saccades, binocular activities) 3. Results are often poor

Question 365

What are the 5 key symptoms, and 4 other symptoms you should ask when asking about the nose?

Answer 365

1. Nasal obstruction 2. Runny nose (aka anterior rhinorrhea) 3. Loss of sense of smell (hyposmia) 4. Nose bleeds (epistaxis) 5. Facial pain 6. Post nasal drip 7. Nasal itch 8. Sneezing 9. Ocular itch

Question 366

What are the 5 key symptoms, and 2 other symptoms, you should ask when asking about the ear?

Answer 366

1. Earache (otalgia) 2. Ear discharge (otorrhea) 3. Hearing loss 4. Tinnitus 5. Dizziness 6. Aural blockage 7. Itching

Question 367

What are the 5 key symptoms, and 3 other symptoms, you should ask when asking about the throat?

Answer 367

1. Sore throat 2. Difficulty swallowing (dysphagia) 3. Pain on swallowing (odynophagia) 4. Hoarse voice (dysphonia) 5. Regurgitation 6. Feeling of a lump in the throat 7. Burning in the throat 8. Weight loss

Question 368

What medical condition is often associated with allergic chronic rhinosinusitis? (1)

Answer 368

Asthma

Question 369

Name 6 systemic conditions that can affect the ears, nose and throat

Answer 369

1. Diabetes 2. Hypertension 3. Sarcoidosis 4. TB 5. Granulomatosis with polyangiitis 6. Neurofibromatosis type 2

Question 370

What structures are found in the anterior triangle of the neck? (4)

Answer 370

1. Carotid sheath 2. Thyroid gland 3. Submandibular gland 4. Lymph nodes (deep cervical)

Question 371

What structure are found in the posterior triangle of the neck? (2)

Answer 371

1. Accessory nerve | 2. Posterior triangle lymph nodes

Question 372

How are lymph nodes in the neck categorized? (7)

Answer 372

Level 1 = submandibular + submental lymph nodes Level 2 - 4 = deep cervical lymph nodes (depending on position relative to sternocleidomastoid: upper-lower) Level 5 = posterior triangle lymph nodes Level 6 = paratracheal Level 7 = upper mediastinal

Question 373

What pathology will result in Level 1 lymphadenopathy? (1)

Answer 373

1. Diseases of the oral cavity

Question 374

What pathology will result in Level 2-4 lymphadenopathy? (3)

Answer 374

1. Oropharynx 2. Hypophayrnx 3. Larynx

Question 375

What pathology will result in Level 5 lymphadenopathy? (1)

Answer 375

1. Lymphoma

Question 376

What are you looking for on general inspection of the neck in an examination? (4)

Answer 376

1. Scars 2. Fistulas 3. Sinuses 4. Masses/swellings

Question 377

What important structures are present within the digastric triangle of the neck? (4)

Answer 377

1. Submandibular gland 2. Internal + external carotid arteries 3. Internal jugular vein 4. Hypoglossal nerve

Question 378

What important structures are present within the carotid triangle of the neck? (4)

Answer 378

1. Carotid sheath (common, internal + external carotid arteries, vagus nerve, sympathetic chain) 2. Hypoglossal nerve 3. Upper part of larynx 4. Lower part of pharynx

Question 379

In someone presenting with throat symptoms, how would the aerodigestive tract be investigated? (1)

Answer 379

Flexible nasendoscope

Question 380

What is a quinsy and why do they occur? (3)

Answer 380

1. Peritonsillar abscess 2. Can occur as a complication of severe bacterial acute tonsillitis 3. Do not respond to antibiotics + must be drained

Question 381

In bacterial infections of the pharynx, where can abscesses develop? (2)

Answer 381

1. Retropharyngeal space | 2. Parapharyngeal space

Question 382

Why is it not uncommon for someone to experience otalgia with sore throat? (2)

Answer 382

1. The glossopharyngeal nerve (CN9) supplies sensation to the throat + ear 2. Called referred otalgia

Question 383

Name 3 common causes of referred otalgia?

Answer 383

1. Pharyngeal pathology 2. The temperomandibular joint 3. Dental infection

Question 384

When examining the ear, what 5 things are you looking for on inspection?

Answer 384

1. Deformity 2. Discharge 3. Scars 4. Sinuses 5. Skin conditions

Question 385

On inspection of the external auditory canal with an auroscope, what 3 things are you looking for?

Answer 385

1. Diameter 2. Debris 3. Swellings

Question 386

On inspection of the tympanic membrane, what 4 things are you looking for?

Answer 386

1. Perforations 2. Refractions 3. Keratin 4. Cavity

Question 387

What are the 2 parts of the tympanic membrane?

Answer 387

1. Pars flaccida ('the attic') | 2. Pars tensa

Question 388

What are the 6 steps of the central auditory pathway?

Answer 388

1. Sounds enter the ear 2. Tiny middle ear bones amplify sound 3. Cochlea sorts sounds by frequency 4. Cochlear nerve (CN7) passes signal from cochlea to brainstem (crosses to contralateral side here) 5. Signal travels through brain getting decoded along the way (superior olivary nucleus -> lateral lemniscus -> inferior colliculus -> medial geniculate body) 6. Auditory cortex recognizes + processes sounds

Question 389

Where is the auditory cortex situated? (3)

Answer 389

1. Superior temporal gyrus of the temporal lobe 2. Lateral sulcus 3. Transverse temporal gyri (Heschl's gyrus)

Question 390

What is the name of the 3 membranous compartments of the cochlear duct, and what fluid runs through them?

Answer 390

1. Scala tympani (perilymph) 2. Scala media (endolymph) 3. Scala vestibuli (perilymph)

Question 391

What is the name of the structure responsible for converting sound waves into an electrical signal that can be interpreted by the brain? (1)

Answer 391

Organ of Corti

Question 392

Name the 3 ossicles of the ear (from lateral to medial)

Answer 392

1. Malleus 2. Incus 3. Stapes

Question 393

How is the electrical signal transferred from the Organ of Corti to the brain? (4)

Answer 393

1. Stereocilia of hair cells deflect resulting in opening of K+ channels 2. Endolymph rich in K+ and Ca2+ pass into the hair cell triggering depolarization + opening of voltage gated Ca2+ channels at the base of the hair cells 3. Results in the release of glutamate causing depolarization of the cochlear nerve that is connected to the basilar membrane sending an electrical signal to the brain

Question 394

What is the primary function of the chord tympani? (2)

Answer 394

1. To carry taste nerves (CN7) from the anterior 2/3 of the tongue from the nucleus of the solitary tract 2. It also carries PSNS secretomotor fibres to the submandibular and sublingual glands.

Question 395

What are the typical features of otitis externa? (3)

Answer 395

1. Painful generalized swelling of the external ear canal 2. Moist ear canal 3. Purulent debris within the ear canal

Question 396

In someone presenting with otitis extenra, what other examinations should be performed? (2)

Answer 396

1. Cranial nerve exam (osteomyelitis of the temporal bone can affect CN 7) 2. Cervical lymphadenopathy exam (pre/post auricular lymph nodes may be inflamed mimicking acute mastoiditis)

Question 397

What protects the outer ear from infection? (4)

Answer 397

1. Wax 2. Shape of the external auditory canal 3. Hair 4. Skin

Question 398

Name 3 risk factors for developing otitis externa

Answer 398

1. Allowing water to enter the ears 2. Instrumentation of the ear canal (i.e. cotton buds) 3. Skin conditions (i.e. eczema, psoriasis)

Question 399

What are the 3 most common causative organisms causing otitis externa?

Answer 399

1. Staph aureus (most common) 2. Aspergillus niger (most common fungal cause) 3. Pseudomonas aeriguinosa

Question 400

If infection spreads to cartilage, what is this called? (1)

Answer 400

Perichondritis

Question 401

Name 2 conditions in which individuals are at risk of developing malignant/necrotising otitis externa

Answer 401

1. Immunocompromised | 2. Diabetes

Question 402

How is otitis externa treated? (3)

Answer 402

1. Keep ear dry 2. Oral analgesia 3. Topical antibiotic drop with steroid (i.e. Sofradex, Gentisone, Otomise)

Question 403

If perichondritis is left untreated, what is the result? (1)

Answer 403

Necrosis of the pinna cartilage which causes pinna deformity ('cauliflower ear')

Question 404

How is perichondritis treated? (3)

Answer 404

1. Admit patient and start course of IV antibiotics 2. Continue topical drops with insertion of aural wick 3. Gentle micro-suction of the ear (remove infected debris)

Question 405

What are the complications of untreated osteomyelitis of the temporal bone (malignant otitis externa)? (3)

Answer 405

1. Sensorineural deafness 2. Inflammation of the cranial nerves (facial nerve) passing through the temporal bone 3. Life threatening

Question 406

What is the commonest cause of acquired hearing loss in children? (1)

Answer 406

Otitis media with effusion | - middle effusion behind an intact tympanic membrane

Question 407

What are 3 complications of untreated acute otitis externa?

Answer 407

1. Facial cellulitis (early complication) 2. Otomycosis (early complication, following use of topical antibacterial agent) 3. Canal stenosis + hearing loss (late complication)

Question 408

How is malignant/necrotising otitis externa treated? (3)

Answer 408

1. Topical antibiotics + IV antibiotics for 6 weeks | 2. Regular assessment (CRP/ESR, MRI skull base)

Question 409

What is the most common organism causing malignant otitis externa? (1)

Answer 409

Pseudomonas aeruginosa

Question 410

What is tympanosclerosis? (3)

Answer 410

1. White plaque within the tympanic membrane 2. Caused by calcium deposition within the membrane from healing of previous ear infections 3. Not of any concern, although can often be mistaken for cholesteatoma (non-cancerous skin growth behind the middle ear)

Question 411

What are 3 causes of a perforated tympanic membrane?

Answer 411

1. Iatrogenic (i.e. ear surgery, grommet insertion) 2. Trauma (i.e. diving, barotrauma) 3. Infection (i.e. recurrent middle ear infections)

Question 412

What are the most common organisms involved in chronic otitis media? (4)

Answer 412

1. Pseudomonas aeruginosa 2. Staph aureus 3. Streptococcus 4. Anaerobic bacteria (i.e. peptostreptococcus)

Question 413

How is otitis media treated? (4)

Answer 413

1. Microsuction + inspection of the ear under microscope 2. Topical antibiotics + steroid drops for 7-10 days (i.e. Sofradex, Gentisone HC, Locorten Vioform, Ciprofloxacin drops) 3. Strict water precautions 4. Myringoplasty (operation to repair ear drum if medical management fails)

Question 414

What is a cholesteatoma? (4)

Answer 414

1. Deep retraction of the tympanic membrane 2. Pars flaccida accumulates keratin from outer skin cells 3. Develops into keratin cyst 4. Can erode the ossicles of the ear

Question 415

What is glomus jugulare? (1)

Answer 415

Tumour involving part of the temporal bone that also involves the middle and inner ear structures

Question 416

What causes retraction of the tympanic membrane, making cholesteatoma more common? (2)

Answer 416

1. Chronic Eustachian tube dysfunction | 2. Negative middle ear pressure

Question 417

How is cholesteatoma managed? (3)

Answer 417

1. Close inspection + cleaning of ear under microscope 2. Pure tone audiogram 3. Topical antibiotics + steroid drops

Question 418

What are 4 antibiotics used to treat otitis media?

Answer 418

1. Sofradex 2. Gentisone HC 3. Locorten Vioform 4. Ciprofloxacin

Question 419

What is the definitive surgical management for cholesteatoma? (1)

Answer 419

Mastoidectomy

Question 420

What are the possible complications associated with middle ear surgery? (9)

Answer 420

1. Infection 2. Bleeding 3. No improvement in hearing 4. Complete loss of hearing (i.e. dead ear - if inner ear is damaged) 5. Tinnitus 6. Vertigo 7. Facial nerve injury, resulting in facial palsy 8. Altered taste (chorda tympani damaged) 9. Recurrence of disease needing revision surgery

Question 421

What is the definition of acute otitis media (AOM)?

Answer 421

Acute inflammation of the middle ear with systemic upset

Question 422

What is the definition of recurrent acute otitis media (RAOM)?

Answer 422

More than 4 episodes of acute otitis media in a 6 month period

Question 423

What is the definition of chronic otitis media (COM)?

Answer 423

Inflammatory condition affecting the middle ear for a period greater than 6 months

Question 424

What are the 2 types of active/inactive chronic otitis media?

Answer 424

1. Squamous epithelial | 2. Mucosal

Question 425

What is the pathophysiology of active mucosal disease?

Answer 425

Occurs in the presence of a perforated tympanic membrane which then allows for infection to develop in the middle ear

Question 426

What is the pathophysiology of active squamous epithelial disease?

Answer 426

Results from cholesteatoma formation

Question 427

What is the pathophysiology of inactive mucosal disease?

Answer 427

Dry perforation of the tympanic membrane

Question 428

What is the pathophysiology of inactive squamous epithelial disease?

Answer 428

Shallow self-cleaning retracted tympanic membrane

Question 429

What type of hearing loss is associated with otitis media with effusion? (1)

Answer 429

Conductive hearing loss

Question 430

What part of the tympanic membrane is more prone to perforation? Retraction? (2)

Answer 430

``` Perforation = pars tensa Retraction = pars flacida ```

Question 431

What are 4 intra-temporal complications that can occur as a result of chronic otitis media?

Answer 431

1. Vertigo (inflammation spreading to labyrinth) 2. Hearing loss (conductive = damage to ossicles/tympanic membrane; sensorineural = inflammation of cochlea) 3. Acute otitis externa (discharge from ear causing skin irritation) 4. Facial weakness (erosion of the thin bony canal in the middle ear can expose inflammation to the facial nerve)

Question 432

What are 4 extra-temporal complications that can occur as a result of chronic otitis media?

Answer 432

1. Meningitis (can erode thru tegmen tympani/roof of middle ear cleft) 2. Subdural abscess 3. Temporal lobe abscess 4. Sigmoid sinus thrombosis

Question 433

In a patient presenting with a neck lump, what questions about the presenting complaint should you ask? (10)

Answer 433

1. Duration - when did it appear 2. Change in size 3. Associated features (pain/redness/discharge) 4. Lumps elsewhere 5. Preceding symptoms (coryzal/tonsillitis/pharyngitis) 6. Recent travel (TB) 7. Contact with TB patients 8. Occupation (petrochemical wood industry) 9. Animals/cat scratches 10. Exposure to radiation

Question 434

What are the 'red flag' symptoms for a neck lump? (7)

Answer 434

1. Persistent sore throat 2. Hoarseness 3. Dysphagia 4. Odynophagia 5. Weight loss 6. Fevers 7. Night sweats

Question 435

What are other important questions to ask someone with a neck lump in a history? (7)

Answer 435

1. Smoking 2. Alcohol 3. Recent foreign travel 4. HIV status 5. Dental problems 6. Contact with TB 7. Other systemic symptoms (i.e. night sweats)

Question 436

With a neck examination, what other areas should be examined? (4)

Answer 436

1. Oropharynx 2. Nasopharynx 3. Larynx 4. Oral cavity

Question 437

What investigations can be useful when investigating a neck lump? (3)

Answer 437

1. Ultrasound (first line) 2. Fine needle aspiration cytology (FNAC) (first line) 3. CT

Question 438

What is the differential for: | moderate-sized lump, rubbery, non-tender, non-fluctuant

Answer 438

Reactive lymphadenopathy

Question 439

Name the 7 categories neck lumps can be organized into

Answer 439

1. Congenital 2. Infectious 3. Inflammatory 4. Neoplastic - benign 5. Neoplastic - malignant 6. Vascular 7. Thyroid

Question 440

What are possible congenital causes for a neck lump? (7)

Answer 440

1. Dermoids 2. Thyroglossal duct cyst 3. Branchial cyst 4. Teratomas 5. Laryngocoele 6. Hemangioma 7. Plunging ranula

Question 441

What are possible infectious causes for a neck lump? (3)

Answer 441

1. Lymphadenopathy - bacterial -> suppurative (staph, strep) - viral (EBV, CMV) - fungal - TB - toxoplasmosis 2. Neck abscess 3. Sialadenitis (infection of salivary gland)

Question 442

What are possible inflammatory causes for a neck lump? (4)

Answer 442

1. Sarcoidosis 2. Kawasaki disease 3. Sinus histiocytosis 4. Castleman's syndrome

Question 443

What are possible benign neoplastic causes for a neck lump? (3)

Answer 443

1. Benign salivary gland tumour 2. Lipoma 3. Sebaceous cyst

Question 444

What are possible malignant neoplastic causes for a neck lump? (3)

Answer 444

1. Metastatic squamous cell carcinoma 2. Lymphoma 3. Malignant salivary gland tumour

Question 445

What are possible vascular causes for a neck lump? (2)

Answer 445

1. Carotid body tumour | 2. Carotid artery aneurysm

Question 446

What are possible thyroid causes for a neck lump? (3)

Answer 446

1. Nodule 2. Goitre (benign or malignant) 3. Thyroiditis

Question 447

What are 5 risk factors for developing squamous cell carcinoma of the head/neck?

Answer 447

1. HIV 2. Smoking 3. Alcohol 4. Betal nut chewing 5. GORD

Question 448

How is a head and neck cancer differential investigated? (3)

Answer 448

1. Panendoscopy + biopsy (look at pharynx, larynx, + upper esophagus under microscope + obtain tissue) 2. CT skull base to diaphragm (looking at extent of primary tumour) 3. Discuss at MDT meeting

Question 449

Hoarseness lasting more than how long warrants urgent referral?

Answer 449

Longer than 6 weeks

Question 450

What area of the neck must be examined in patients with dysphonia? (1)

Answer 450

Larynx

Question 451

What are the causes of dysphonia? (10)

Answer 451

1. Overuse 2. Acute laryngitis 3. Chronic laryngitis 2º to reflux 4. Use of asthma inhalers 5. Smoking 6. Squamous cell carcinoma of the larynx 7. Vocal cord palsy 8. Lymphadenopathy 9. Malignant thyroid disease (invades recurrent laryngeal nerve) 10. GORD

Question 452

What is Reinke's oedema? (3)

Answer 452

1. Vocal folds become oedematous with accumulation of a gelatinous material within the vocal folds 2. Most commonly occurs in females + smokers 3. Tx = smoking cessation, control of GORD, incision in vocal folds with evacuation of gelatinous material

Question 453

What treatments are available for head and neck cancer? (5)

Answer 453

1. Radiotherapy (very effective - curative or palliative) 2. Surgical (very effective/curative - resection of cancer) 3. Chemotherapy (palliative) 4. Palliative management (symptomatic control) 5. Rehabilitation (recovery of function - i.e. voice/swallowing problems)

Question 454

How are head and neck cancers classified?

Answer 454

TNM staging - Tumour (1-4) - Nodes (1-3) - Metastasis (1-2)

Question 455

What are the possible differentials for a lump in the midline of the neck? (4)

Answer 455

1. Thyroglossal cyst 2. Dermoid cyst 3. Thyroid lump/goitre 4. Cervical lymphadenopathy

Question 456

What are causes for a benign solitary thyroid nodule? (3)

Answer 456

1. Follicular adenoma 2. Hyperplastic nodules 3. Thyroid cysts

Question 457

What are causes for a malignant solitary thyroid nodule? (4)

Answer 457

1. Papillary carcinoma 2. Follicular carcinoma 3. Medullary carcinoma 4. Anaplastic carcinoma

Question 458

Name 4 common causes of generalized thyroid swelling?

Answer 458

1. Physiological (pregnancy, puberty) 2. Degenerative (multinodular goitre) 3. Thyroiditis (Hashimoto's disease) 4. Grave's disease

Question 459

What symptoms associated with a thyroid lump make you suspicious of a thyroid malignancy diagnosis? (5)

Answer 459

1. Rapidly enlarging painless thyroid mass 2. Thyroid nodule in child (rare in children so needs to be urgently investigated) 3. Stridor (strongly indicative of malignancy) 4. Unexplained hoarseness (suggests invasion of the recurrent laryngeal nerve or larynx) 5. Enlarged cervical lymph nodes (benign thyroid masses aren't associated with lymphadenopathy)

Question 460

What is the likely primary treatment option that the MDT will recommend for this patient who has been referred with a new diagnosis of thyroid cancer? (1)

Answer 460

Thyroidectomy (surgery)

Question 461

What are the mechanisms of malignant neoplasms development on a cellular level? (3)

Answer 461

1. Activation of growth promoting oncogenes (i.e. cyclin, D1, EGF) 2. Inactivation of cancer suppression genes (i.e. p16, p53) 3. Alteration of genes controlling programmed cell death (apoptosis)

Question 462

What is the commonest malignancy of the thyroid gland? (1)

Answer 462

Papillary carcinoma

Question 463

What is the most common site of head and neck squamous carcinoma in adults? (1)

Answer 463

Oral cavity

Question 464

Which head and neck cancer can result in hearing loss?

Answer 464

Nasopharyngeal carcinoma - results in otitis media with effusion thru obstruction of the Eustachian tube

Question 465

What key questions should you ask a patient presenting with nasal symptoms? (6)

Answer 465

1. Is it both sides or one that feels blocked? 2. How long has it been blocked for and is it intermittent or constant? 3. Any history of trauma? 4. Previous nasal surgery? 5. Other nasal symptoms (sneezing, rhinorrhea, facial pain, post nasal drip, epistaxis) 6. What medications are they using?

Question 466

What are causes of a nasal septum deformity? (4)

Answer 466

1. Infective 2. Inflammatory conditions (Granulomatosis with polyangiitis, sarcoidosis) 3. Trauma 4. Congenital

Question 467

What is the management for deviated nasal septum? (1)

Answer 467

Septoplasty

Question 468

What 5 components should be included when gaining consent for a medical procedure?

Answer 468

1. Risks 2. Benefits 3. Diagnosis + prognosis 4. Other treatment options (including no treatment) 5. Explanation of the procedure

Question 469

What are risks of septoplasty? (8)

Answer 469

1. Septal perforation 2. Further procedure/revision surgery 3. Numbness of upper teeth 4. Bleeding + infection 5. Altered appearance 6. Numbness to nose 7. Failure to improve symptoms 8. Anosmia/hyposmia

Question 470

What is the differential for: | - bilateral nasal obstruction, anterior rhinorrhea, sneezing, nasal mucosa oedema, watery discharge from nose

Answer 470

Chronic Rhinosinusitis without polyps

Question 471

What investigation would be useful for chronic Rhinosinusitis without polyps? (1)

Answer 471

RAST testing (radioallergoabsorbant) - blood test that identifies any allergies to specific allergens

Question 472

What are the treatments for chronic rhinosinusitis without polpys? (4)

Answer 472

1. Saline nasal irrigation 2. Topical nasal steroid 3. Antihistamine 4. Surgery (only if pt doesn't respond to medical tx)

Question 473

Name 3 examinations that you would perform on a patient presenting with nasal obstruction

Answer 473

1. Anterior rhinoscopy 2. Inspection of external nose 3. Nasal endoscopy

Question 474

What investigations would you request for chronic rhinosinusitis with polyps? (2)

Answer 474

1. CT sinuses | 2. RAST testing

Question 475

How would you treat a patient with chronic rhinosinusitis with polyps? (3)

Answer 475

1. Short course of prednisolone (shrinks polpys) 2. Topical nasal steroid (long-term use) 3. Functional endoscopic sinus surgery (if symptoms don't resolve with medical management)

Question 476

What are possible risks of performing functional endoscopic sinus surgery? (10)

Answer 476

1. Epiphoria 2. Hyposmia/anosmia 3. Orbital injury 4. CSF leak 5. Bleeding 6. Infection 7. Synechiae (adhesions in nasal cavity) 8. Blindness (operating close to optic nerve) 9. Meningitis (if dura is breached) 10. Recurrence

Question 477

What epithelium lines the paranasal sinuses?

Answer 477

Ciliated epithelium

Question 478

What are the components that make up the external anatomy of the nose, from proximal to distal? (6)

Answer 478

1. Root 2. Dorsum 3. Apex 4. Naris 5. Nasal septum 6. Ala

Question 479

What are the components that make up the internal anatomy of the nose, from proximal to distal? (9)

Answer 479

1. Frontal sinus 2. Superior conchae 3. Ethmoid sinus 4. Middle conchae 5. Nasal cavity 6. Mucus membrane 7. Nasal septum 8. Maxillary sinus 9. Inferior conchae

Question 480

What is the diagnostic criteria for rhinosinusitis? (6)

Answer 480

Inflammation of the nose + paranasal sinuses characterized by nasal blockage/congestion/obstruction + 1 or more of the following: 1. Facial pain/pressure 2. Reduction/loss of sense of smell 3. Nasal polyps 4. Mucopurulent discharge 5. CT changes

Question 481

What is the definition of acute rhinosinusitis?

Answer 481

Lasts < 12 weeks with complete resolution of symptoms

Question 482

What is the definition of chronic rhinosinusitis?

Answer 482

Lasts > 12 weeks without complete resolution of symptoms

Question 483

What topical steroids are used as a nasal spray in the treatment of rhinosinusitis? (3)

Answer 483

1. Beclomethasone 2. Fluticasone 3. Mometasone

Question 484

What is the antibiotic of choice for rhinosinusitis with evidence of infection? (1)

Answer 484

Macrolides (clarithromycin)

Question 485

How is allergic rhinitis diagnosed? (3)

Answer 485

1. History of 2+ nasal symptoms 2. Nasal examination showing inflammatory changes 3. Sensitization by skin prick tests or specific IgE tests

Question 486

How is allergic rhinitis treated? (3)

Answer 486

1. Oral/intranasal antihistamines 2. Intranasal steroids 3. Leukotriene receptor antagonists

Question 487

Name 4 common causes of nasal obstruction

Answer 487

1. Nasal polpys (unilateral = red flag = anterochoanal polpy/sinonasal neoplasm = benign/malignant) 2. Nasal septum deviation 3. Chronic rhinosinusitis (most common cause) 4. Foreign body in the nose (common in kids)

Question 488

What 3 methods are used to assess nasal patency?

Answer 488

1. Nasal misting on the back of a metal spatula 2. Nasal inspiratory peak flow 3. Acoustic rhinometry

Question 489

What method is used to test the function of the Eustachian tube? (1)

Answer 489

Valsava manoeuvre

Question 490

Name 4 causes of anosmia

Answer 490

1. Trauma 2. Iatrogenic injury 3. Idiopathic (most common) 4. Neurodegenerative conditions (i.e. PD)

Question 491

What medical conditions predispose to epistaxis? (9)

Answer 491

1. HTN 2. Inflammatory (chronic granulomatous disease/granulomatosis with polyangiitis, sarcoidosis) 3. Hematological disorders (HHT, Hemophilia, DIC, ITP) 4. Acute/chronic rhinosinusitis 5. Trauma 6. Neoplasia (i.e. squamous cell carcinoma, adenocarcinoma, inverted papilloma, juvenile angiofibroma) 7. Idiopathic (>85% of cases) 8. Iatrogenic (recent nasal surgery) 9. Drugs (clopidogrel, aspirin, warfarin, LMWH)

Question 492

What medication can predispose epistaxis? (4)

Answer 492

1. Clopidogrel 2. Aspirin 3. Warfarin 4. LMWH

Question 493

What examinations are relevant to perform in someone presenting with chronic epistaxis? (3)

Answer 493

1. Anterior rhinoscopy 2. Inspection of the external nose 3. Posterior rhinoscopy

Question 494

What devices can be used for an anterior rhinoscopy examination? (2)

Answer 494

1. Thuddicum's speculum | 2. Otoscope

Question 495

What is the difference between a flexible and rigid endoscope, used in posterior rhinoscopy? (2)

Answer 495

1. Quality of picture (better with rigid endoscope) | 2. Extent of examination (examination of larynx + pharynx with flexible endoscope)

Question 496

Bleeding from what area of the nose accounts for 85% of epistaxis episodes? (1)

Answer 496

Little's area/Kiesselbach's plexus

Question 497

What 3 arteries are found in the Kiesselbach's plexus?

Answer 497

1. Anterior ethmoid artery 2. Sphenopalatine artery 3. Greater palatine artery

Question 498

What are the treatment options for someone with recurrent epistaxis? (3)

Answer 498

1. Naseptin ointment (keeps area moist, prevents crusting) 2. Epistaxis advice 3. Silver nitrate cautery to the affected area

Question 499

Which blood tests would be warranted in a patient with severe epistaxis and coughing up blood clots? (3)

Answer 499

1. FBC 2. Coagulation profile 3. Group + save

Question 500

How is persistent epistaxis managed? (5)

Answer 500

1. Admit patient to ENT ward 2. Cauterise (if can visualize bleeding point) 3. Anterior nasal packing 4. Posterior nasal packing (if bleeding thru anterior packs; 48h only) 5. Surgery (if not resolved with posterior pack)

Question 501

What are the 2 common vessels that lead to a posterior nasal bleed?

Answer 501

1. Sphenopalatine artery (forms part of Woodruff plexus) | 2. Anterior ethmoidal artery

Question 502

What are the components of epistaxis advice? (4)

Answer 502

1. Avoid hot drinks for 2 weeks 2. Avoid hot baths/showers 3. Avoid picking the nose 4. Avoid very hot/spicy foods

Question 503

What is the most common postnasal space malignancy, and what population group are most at risk? (2)

Answer 503

1. Squamous cell carcinoma (i.e. nasopharyngeal carcinoma) | 2. Chinese origin

Question 504

Tranexamic acid is sometimes used to help stop bleeding in cases of epistaxis. How does it work?

Answer 504

1. Anti-fibrinolytic agent | 2. They inhibit the activation of plasminogen to plasmin, prevent the break-up of fibrin and maintain clot stability.

Question 505

In which patients is tranexamic acid contraindicated? (8)

Answer 505

1. Blood clots 2. Bleeding 3. Heart valve problems 4. Visual problems 2º to bleeding 5. Irregular heartbeat 6. Irregular unexplained menstrual bleeding 7. Birth control/devices 8. Meds such as clotting factors + meds with tretinoin

Question 506

A hemoglobin below X often warrants transfusion. What is the value of X?

Answer 506

7