Ophthalmology/ ENT

Question 1

What is conjunctivitis

Answer 1

inflammation of the conjunctiva which is a thin layer of tissue that covers the inside of the eyelids and the sclera

Question 2

What are the features of bacterial conjunctivitis

Answer 2

• purulent discharge
• worse in the morning, eyes may be stuck together

Question 3

Give 2 causes of bacterial conjunctivitis

Answer 3

• Staphylococcus aureus
• Pneumococcus

Question 4

What are the features of viral conjunctivitis

Answer 4

• clear, serous discharge
• recent URTI
• tender, preauricular lymph nodes (in front of ears)

Question 5

Give 2 causes of viral conjunctivitis

Answer 5

• adenovirus
• herpes simplex

Question 6

How is infective conjunctivitis managed

Answer 6

• usually resolves in 1-2 weeks without treatment
• hygiene - don’t share towels, hand washing etc
• topical antibiotics (eyedrops/ ointment) - e.g. Chloramphenicol or fusidic acid (pregnant women)
• contact lenses should not be worn during an episode

Question 7

What causes allergic conjunctivitis

Answer 7

contact with allergens, most commonly seen in context of hay fever

Question 8

Describe the features of allergic conjunctivitis

Answer 8

• Bilateral symptoms: conjunctival erythema and swelling (chemosis)
• watery eyes
• prominent itch
• swollen eyelids

Question 9

How is allergic conjunctivitis managed

Answer 9

• 1st line: topical or systemic antihistamines, e.g. epinastine
• 2nd line: topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil

Question 10

Give 5 differentials for an acute painful red eye

Answer 10

• Acute angle closure glaucoma
• Anterior uveitis
• Scleritis
• corneal abrasions
• traumatic or chemical injury

Question 11

Give 5 features of anterior uveitis

Answer 11

• acute onset
• painful, red eye
• blurred vision
• photophobia
• small, fixed oval pupil, ciliary flush (ring of red)

Question 11

Give 5 features of acute angle closure glaucoma

Answer 11

• severe pain (may be ocular or headache)
• decreased visual acuity, patient sees haloes around lights
• fixed, semi-dilated non-reacting pupil
• hazy cornea
• red eye

Question 11

Give 3 differentials for an acute painless red eye

Answer 11

• conjunctivitis
• episcleritis
• subconjunctival haemorrhage

Question 12

Give 3 features of scleritis

Answer 12

• red, inflamed sclera
• severe pain that may be worse of movement
• tenderness to palpation
• systemic conditions: rheumatoid arthritis, granulomatosis with polyangiitis

Question 13

What typically precedes subconjunctival haemorrhages

Answer 13

episodes of strenuous activity
* heavy coughing
* trauma
* weight lifting
* straining when constipated

Question 14

What is the most common cause of tonsilitis

Answer 14

a viral infection

Question 15

What are the 2 most common causes of bacterial tonsilitis

Answer 15

• group A streptococcus (Streptococcus pyogenes)
• Streptococcus pneumoniae

Question 16

Give 5 features of acute tonsillitis

Answer 16

• Sore throat
• Fever (above 38°C)
• Pain on swallowing
• red, inflamed and enlarged tonsils, with or without exudates
• anterior cervical lymphadenopathy

Question 17

What criteria is used to estimate the probability that tonsilitis is due to bacterial infection

Answer 17

Centor criteria or FeverPAIN score

Question 18

How is tonsillitis managed

Answer 18

• viral: safety net (3d) , simple analgesia
• bacterial: antibiotics - penicillin V for 10 days or clarithromycin if CI

Question 19

Give some complications of tonsillitis

Answer 19

• peritonsillar abscess (quinsy)
• otitis media
• rheumatic fever
• glomerulonephritis

Question 20

What are the indications for tonsillectomy

Answer 20

• the person has had: 7 or more episodes in 1 year, 5 per year for 2 years, or 3 per year for 3 years
• recurrent peritonsillar abscess
• obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils

Question 21

complications of tonsillectomy

Answer 21

• Primary (<24 hours): haemorrhage commonly due to haemostasis, pain
• Secondary (24hrs - 10d): haemorrhage commonly due to infection, pain

Question 22

How are post-tonsillectomy haemorrhages managed

Answer 22

• assessed by ENT
• Primary haemorrhage within hours after surgery requires immediate return to theatre
• admit and give antibiotics if wound infection

Question 23

What is acute sinusitis

Answer 23

inflammation of the mucous membranes of the paranasal sinuses

Question 24

What are the most common infectious agents seen in acute sinusitis

Answer 24

* Streptococcus pneumoniae * Haemophilus influenzae * rhinoviruses.

Question 25

Give 4 predisposing factors to acute sinusitis

Answer 25

* nasal obstruction e.g. septal deviation or nasal polyps * recent local infection e.g. rhinitis or dental extraction * swimming/diving * smoking

Question 26

Describe the presentation of acute sinusitis

Answer 26

* facial pain - worse on bending forward * nasal discharge: usually thick and purulent * nasal obstruction * 'double-sickening' may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection

Question 27

How is acute sinusitis managed

Answer 27

* analgesia * intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days * oral antibiotics are not normally required but may be given for severe presentations. * phenoxymethylpenicillin first-line, co-amoxiclav if systemically very unwell

Question 28

What is otitis externa

Answer 28

Inflammation of the skin in the external ear canal

Question 29

Causes of otitis externa

Answer 29

* infection: S.aureus, Pseudomonas aeruginosa, candida * seborrhoeic dermatitis * contact dermatitis (allergic and irritant) * recent swimming is a common trigger

Question 30

Features of otitis externa

Answer 30

* ear pain * itchiness * discharge

Question 31

Findings of otitis externa on otoscopy

Answer 31

red, swollen, or eczematous canal

Question 32

How is otitis externa initially managed

Answer 32

* topical antibiotic +/- steroid (e.g. neomycin + betamethasone) * if tympanic membrane is perforated, aminoglycosides are not used as they're potentially ototoxic * if there is canal debris then consider removal * if the canal is extensively swollen then an ear wick is sometimes inserted

Question 33

What are the second line options for managing otitis externa

Answer 33

* oral antibiotics (flucloxacillin) if the infection is spreading * taking a swab inside the ear canal * poor response to topical antibiotics should be referred to ENT * empirical use of an antifungal agent

Question 34

What is malignant otitis externa

Answer 34

severe form of otitis externa where there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal

Question 35

What does malignant otitis externa progress to

Answer 35

temporal bone osteomyelitis

Question 36

RFs of malignant otitis externa

Answer 36

* diabetics - 90% * immunocompromised

Question 37

What organism most commonly causes malignant otitis externa

Answer 37

Pseudomonas aeruginosa

Question 38

Features of malignant otitis externa

Answer 38

* Severe, unrelenting, deep-seated otalgia * Temporal headaches * Purulent otorrhea * Possibly dysphagia, hoarseness, and/or facial nerve dysfunction

Question 39

How is malignant otitis externa managed

Answer 39

* CT typically done * admission for IV antibiotics (ciprofloxacin) * non-resolving otitis externa with worsening pain should be referred urgently to ENT