Surgery C Flashcards

Question

What is ischaemic optic neuropathy?

Answer 1

Ischaemic optic neuropathy presents with jaw claudication and other associated symptoms without a visual field defect. It is caused by GCS and requires urgent steroids or vision will be lost. It will spread to the other eye if not treated.

Answer 2

If a patient has a hypopyon then ask if they have had surgery in the last 72 hours. If yes, that is opthalmolitis until proven otherwise and is an emergency.

Answer 3

Red eye assessment: Vision affected or not, pain, location (entire eyeball or conjunctiva), cornea affected or not, and pupil size. Causes include hemorrhage, acute glaucoma, corneal abrasion, conjunctivitis, iritis, or others.

Answer 4

Sudden onset pain in young child is AOM and followed by discharge and pain relief is also AOM with perforation.

Answer 5

Hours onset of worsening pain in older children with small amount of discharge and pain when moving the ear is cholesteatoma.

Answer 6

Adenoids can cause blockage of the nostril in young children. Spatula under the nose for condensation is important to test for this. Adenoids present with mouth breathing, nasal obstruction, runny nose and OSA.

Answer 7

Tonsilectomy is performed for recurrent tonsilitis (5 per year for 2 years), OSA and a unilaterally enlarged tonsil.

Answer 8

Epistaxis should be managed by squeezing the nose for 5 mins, leaning forward and remaining calm. Medical treatment is naseptin, cautery, dressing and then blood loss management for shock. A Merocele is used when the bleeding cannot be stopped.

Answer 9

Nasal polyps

Answer 10

Hard, irregular, immobile, larger than 2cm, involving the supraclavicular nodes or there is a thyroid mass.

Answer 11

croup (Steeple sign on CXR), foreign bodies and epiglottitis.

Answer 12

red flags include 2-3 weeks, immunosuppressed, over 40, tobacco, alcohol, unexplained weight loss, previous history of malignancy, dysphonia, blood in saliva, dysphagia, odynophagia or otalgia.

Answer 13

Tongue tie affects breast feeding rather than bottle feeding in whom it presents with speech development issues.

Answer 14

Most wounds will heal spontaneously; superficial and small wounds will heal within days to weeks whereas deep and larger wounds take weeks to months. Complex wounds, especially those with non-vascular wound beds, may never heal. Wounds heal via a process of inflammation, proliferation, and then remodeling. Scarring may result depending on the depth and severity of the original wound, the time to healing, and the wound closure technique employed.

Answer 15

Split thickness skin grafts are epidermis and variable amounts of dermis. The donor site heals within two weeks. It can be sheet, fenestrated, meshed, or meek.

Answer 16

This is epidermis and dermis, and the donor site is closed directly to limit the size.

Answer 17

This involves moving adjacent tissue to fill a defect which can be advancement, transposition or rotational. The donor site is then closed. The vascular supply of the flap and the area of the flap that is in continuity with the donor site is the pedicle. This gives a better aesthetic and is often used post radiotherapy.

Answer 18

This involves use of non-directly adjacent tissue in the same vicinity as the wound; the flap donor site is not in direct proximity or communication with the wound. This is used when there is insufficient volume for a local flap. These are still connected by a pedicle to the donor site.

Answer 19

Tissue is moved with its blood supply and anastomosed to another part of the body and can be used when there are no available local options, or skin grafts are not possible. Free flaps are often used to reconstructs defects secondary to trauma or cancer such as the DIEP flap.

Answer 20

Treatment options include surgical excision and reconstruction, Mohs, topical chemotherapy and radiotherapy.

Answer 21

Stop the burning process, 20 mins cool running water within 3 hours of the burn and then keep warm. ABCDE include inhalation injuries and size of the burn with TBSA. Major burns resuscitation is with the TBSA, IV fluids as per Parkland formula, consider fasciotomy or escharotomy, wound debridement and dressing and then ITU/HDU care.

Answer 22

- Aged under 16: Likely inflammatory or congenital. - Aged 16 – 40: Inflammatory or congenital causes are still most common, but malignancy incidence begins to increase. - Over 40: These should be considered neoplastic and potentially malignant until proven otherwise, especially in a history of smoking or excessive alcohol use. RED FLAGS for malignancy: Lump present for more than 2-3 weeks, patient older than 40, tobacco or alcohol use, previous malignancy, immunocompromised status, unexplained weight loss, ulcers, change in voice, blood in saliva, dysphagia, odynophagia, and otalgia.

Answer 23

1. General inspection: sweating and clothing. When palpating thyroid stand behind. 2. Hands: examine for tremor, outstretched hands, sweaty palms, thyroid acropachy similar to clubbing, and palmar erythema. 3. CVS: Tachycardia/AF is seen in hyperthyroidism and bradycardia is seen in hypothyroidism. 4. Eyes: Loss of outer 3rd of eyebrows, exophthalmos, chemosis, red sclera, and lid lag 5. Auscultation: Bruits 6. Legs: Pre-tibial myxoedema (non-pitting oedema) 7. Pemberton’s test: Raising both arms produces facial congestion and cyanosis due to mass in superior mediastinum which occur when retrosternal goitre obstructs the vena cava.

Answer 24

This is found from the zygomatic arch to ear lobe, behind the ramus of the mandible. The deep lobe extends behind the ramus of the mandible. 80% of tumours are benign. Any patient with a parotid lump and a facial palsy has a malignant tumour.

Answer 25

Burns are defined as an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. Thermal burns occur when some or all of the cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns) or flames (flame burn). In a burn, the Jackson burn model shows that there is a zone of coagulation (irreversible tissue loss due to coagulative necrosis), zone of stasis (decreased tissue perfusion which can deteriorate to necrosis) and a zone of hyperaemia (outermost zone with increased tissue perfusion which will recover in the absence of infection). Burn shock occurs because of a mixture of oedema, hypovolemia, coagulability and inflammation. Fluid resuscitation is required for burns over 15% in adults and 10% in children. This is because there is rapid fluid loss through the burnt skin which can compromise the vascular stability of the patient.

Answer 26

When assessing burn surface area: Wallace’s rule of nines whereby each upper limb is 9%, anterior/posterior lower limb is 9%, anterior torso is 18% and head and neck 9% and genitals 1%. The palmar surface area is where each palm represents 1% TBSA. The Lund and Browder chart is a diagrammatic representation of the body which can be used. The depth of the burn is extremely important. This is described as degrees of burns or through burn depth assessment.

Answer 27

Superficial burns are epidermal burns. They do not have blistering and are not included in the TBSA calculations. They may be pink and painful such as sunburn. Partial thickness burns (dermal) can be superficial dermal or deep dermal. Superficial partial thickness burns are salmon pink, blanching with blisters and very painful. Deep dermal injuries are mottled cherry colour that do not blanch. Blood is fixed within damaged capillaries in the deep dermal plexus. There is variable pain but less painful than superficial partial thickness burns. Full thickness burns present as dry, leathery or waxy, hard wound that does not blanch are typically white in colour and painless.

Answer 28

Stop the burning and run the burn under lukewarm water for 20 minutes. Add cling film. Perform an ABC trauma assessment and assess weight. Inhalational injury is common and needs proactive management. Early analgesia is required. All patients should be provided tetanus prophylaxis. The burn depth and TBSA should be assessed as deep chest wall or abdomen burns can restrict ventilation. The presence or absence of vascular compromise from circumferential burns that may require urgency eschartarotomy or fasciotomy. Patient should be kept warm as they are at high risk of hypothermia. Major burns are treated in intensive care. The age of patient plus TBSA over 100 is poor prognosis and 120-150 in likely non-survivable. Fluid resuscitation is calculated on the TBSA and weight of the patient. Resuscitation is Parkland (crystalloid), Muir and Barclay (colloid) and hybrid. Urine output is aimed to be 0.5ml – 1ml/kg/hr and in children it should be between 1-2.

Answer 29

Lacerations and stab wounds are surgically debrided, and a skin graft or reconstruction may be required., Hand injuries should also be surgically debrided and vascular compromise will require microvascular repair. Amputated digits are often salvageable. Animal and human bites also require debridement, antibiotics and closure.

Answer 30

Necrotising fasciitis is a severe and rapidly progressing life threatening soft tissue infection. It is most commonly caused by Strep group A and anaerobes. There is higher incidence in diabetics, especially forneiers gangrene. It is rapidly spreading, and intensive care is needed. Multiple IV antibiotics, renal support or dialysis, inotropes and emergency debridement as every minute counts. Meningococcal sepsis can also cause extensive loss of soft tissues.

Answer 31

The Gustilo and Anderson classification is used for open fractures of the lower limb. The ATLS approach should be used but early and thorough surgical debridement is required in compounds fractures. Reconstruction within 72 hours is required to reduce the risk of chronic osteomyelitis. Compartment syndrome is common and should undergo fasciotomy.

Answer 32

The reconstructive ladder is as follows: 1. Allow to heal 2. Primary closure 3. Skin graft (split thickness or full thickness) 4. Local flap 5. Regional flap 6. Free flap (autotransplant)

Answer 33

The examination is with look, feel, move. Assess neurovascular function and motor function. The most common injuries are digital branches of nerves. A nerve transection is a Neurotmesis where axonotmesis is partial nerve division and neuropraxia is bruising. Damaged nerves are repaired with microsurgery.

Answer 34

The transfer of tissue without a blood supply is categorised according to tissue of origin. This can be autograft (patient), allograft (same species), or Xenograft (animal). Split thickness skin grafts are 0.008-0.012 inches involve the epithelium and thin reticular layer of elastin. Medium thickness grafts are most commonly used (0.012-0.018) whereas thick split thickness grafts (0.018-0.03) are used in face and flexor surfaces where contraction is minimal. Full thickness skin grafts involve the epidermis, dermis and small amount of hypodermis. They are stitched on. Skin is commonly taken from the anterior thigh or buttock.

Answer 35

A flap is a unit of tissue which maintains its own blood vessels whilst being transferred from a donor site to a recipient site. They can be random, pedicled or free. They are classified by circulation, contiguity (distant/local pedicled/free) and composition (singe or composite).

Answer 36

These grafts heal by secondary intention over 2-3 weeks. The basal cells layers in epidermal appendages de-differentiate into basoloid morphology. They migrate into the defect by diapedesis until there is contact inhibition. Contact signal beginning re-differentiation into stratified corneal epithelium layers. In the first 24-48 hours plasmatic inhibition occurs where nutrients and oxygen infiltrate through capillaries. Fibrin bridges are created which is why compressive dressings ar4 required. From 36-48 hours Inosculation occurs. Capillary buds sprout through the skin graft and connect to pre-existing vascular channels and create new ones. Collagen bridges are created. Neurotization occurs later where nerve buds from the bed grows into the graft but sensation takes many months. Sebaceous glands and sweat glands do not regenerate.

Answer 37

Indications for a skin graft are well vascularised, non-infected beds. Contra-indications include flexion areas, constant sheer and friction, infection, cancer and non-vascularised bed. Complications include failure (non-take_, hyperpigmentation (thin) or hypopigmentation (thick), contraction, meshed appearance, dryness and scaling. Primary contraction occurs due to elastin fibres in the dermis. It is more pronounced in FTSG and can be corrected by stretching the graft. Secondary contraction is more severe in thinner STSG, especially if meshed. May reach 40% surface. This is corrected with prolonged splinting. Contracture is where a function or joint is limited. Meshed grafts are the most common but least cosmetically acceptable. They have more contractures but better take. They cover wider surfaces and irregularities and conform better to wound geography.

Answer 38

Otitis Externa is inflammation or infection of the outer ear. This includes the pinna and ear canal. It can be non-infective such as eczema or psoriasis but is most commonly bacterial (or fungal). Bacterial causes include pseudomonas aeruginosa, Staph aureus, E.coli and fungal causes are candida or aspergillus. Management: Non-infective: betamethasone drops Infective: 1st line is acetic acid, aluminium acetate drops, ciprofloxacin drops, or Gentamicin + hydrocortisone drops. There is IV ototoxicity ,but drops are ok. If there is significant debris then an aural toilet with micro-suction is required. If there is evidence of cellulitis then oral antibiotics are indicated (flucloxacillin, ciprofloxacin or metronidazole). Any anaerobic infection requires metronidazole.

Answer 39

Malignant otitis externa (Benign necrotising) is usually seen in elderly diabetic patients or immunocompromised. The infection spreads from the skin of the ear canal into the skull base and causes osteomyelitis. There will be severe pain and granulation of the floor of the ear canal and same day admission to ENT is required.

Answer 40

Chronic suppurative otitis media can be split into inactive (perforated eardrum without infection) and active (with infection and/or cholesteatoma). Active CSOM may respond to topical antibiotics (ciprofloxacin drops or Gentamicin + hydrocortisone drops) or surgery with Tympanoplasty (closing the ear drum).

Answer 41

Cholesteatomas are accumulations of squamous epithelium within a retraction pocket on the ear drum. They arise in the posterosuperior part of the ear drum (pars flaccida). If they are left alone they can cause deafness (ossicular damage or inner ear damage), dizziness (semicircular canal damage), facial palsy (bony erosion of the facial canal) or meningitis.

Answer 42

Patient needs to be asked what dizziness means: light headed, ‘detached from reality' or vertigo. Vertigo is a hallucination or movement, often rotary but can be linear or the feeling that you are on a boat. The duration of the vertigo and the associated symptoms often gives the diagnosis.

Answer 43

Benign Paroxysmal Positional Vertigo: This is diagnosed by the history of vertigo induced by rolling over in bed with a few seconds delay and around 30 seconds of vertigo. Diagnosis can be confirmed by the Dix-Hallpike manoeuvre where torsional nystagmus can be observed. Treated with the Epley Manoeuvre or Brandt-Daroff exercises.

Answer 44

Meniere’s disease has an unknown aetiology and is episodic. There is often a preceding aura (tinnitus or aural fullness) and the rotary vertigo will last for hours. It is associated with sensorineural deafness during the attack with partial recovery afterwards. There will be gradual sensorineural loss over time with repeated attacks. Management is with prochlorperazine, betahistine hydrochloride, low salt diet, thiazide diuretics, transtympanic steroids or chemical labyrinthectomy (gentamicin ablation). Hearing aids may be eventually required. Tinnitus treatment is with sound enrichment or CBT. Vestibular rehabilitation exercises (Cooksey-cawthorne exercises) can be used to treat the dizziness.

Answer 45

Vestibular neuronitis is inflammation or infection (usually viral) of the vestibular nerve. Therefore, vertigo is the only ontological symptom but it is usually accompanied by nausea and vomiting.

Answer 46

Labyrinthitis is inflammation or infection, usually viral, of the labyrinth structures (semi-circular canal, saccule or utricle). This is associated with other ontological symptoms including deafness and tinnitus.

Answer 47

Both vestibular neuronitis and Labyrinthitis have spontaneous onset, may follow a URTI, present with severe rotary vertigo for over a week and the patient is initially bed bound. This will gradually subside over 6 weeks or so as central compression occurs. They will benefit with prochlorperazine in the first week but this should not be continued as it prevents the brain from compensation and thus stops spontaneous recovery. Cooksey-Cawthorne exercises for dizziness will also be helpful.

Answer 48

Vestibular migraine is episodic and most will have a headache. Headache may precede, occur during or after the vertigo. There is often a personal history of classic migraine and it is associated with photo and phono phobia. There may be visual aura as well. Management is to identify the triggers with a food diary and bedtime routine. Tryptans can be used to treat acute attacks but are contraindicated in CVD, HTX, and liver disease. Preventatives such as betablockers, Calcium channel blockers, antiepileptics (Gabapentin) and tricyclic antidepressants (nortriptyline) can be considered.

Answer 49

Adenocystic carcinoma breaks the rule of UMN sparing of the forehead because it can invade the nerves of the lower face, presenting with UMN symptoms but in reality a LMN palsy.

Answer 50

Bell’s palsy is the most common cause of LMN facial palsy and is idiopathic. The LMN runs from the geniculate ganglion, through the middle ear and mastoid, out through the stylomastoid foramen and into the parotid where it branches before supplying the muscles of facial expression. Pathology along this path can damage the nerve.

Answer 51

Facial palsy can be graded by the House-Brackmann 1-6 score: 1. Normal 2. A bit weak 3. Eye closure 4. Unable to close eye 5. A bit of movement 6. Complete palsy

Answer 52

When assessing a VII palsy always check for vesicles (Ramsey-Hunt syndrome), look in the ear for infection/tumour/cholesteatoma, feel parotid for masses, document eye ability and remember parasympathetic involvement causing fewer tears and drying of the eyeball. Management is with prednisolone (1mg/kg) daily for a week and taper 10mg every 3 days thereafter. PPI cover as needed. Viscotears or similar may be needed and lacrilube for nighttime. If Ramsey-Hunt then valacyclovir is required.

Answer 53

Conductive, sensorineural, or cortical Conduction (lesion in the ear canal, drum, or ossicles) Sensorineural (lesion in cochlea or nerve) Cortical (lesion in brainstem/auditory cortex)

Answer 54

Conductive hearing loss is impairment of sound reaching the cochlea and can be caused by wax, otitis externa, perforated tympanic membrane, otitis media with effusion and otosclerosis. These are generally reversible or treatable.

Answer 55

Sensorineural hearing loss can be congenital but is acquired through presbyacusis, Meniere’s disease, Barotrauma, ototoxicity, meningitis and autoimmune conditions. It is not always reversible.

Answer 56

Cortical hearing loss are often following intracranial pathology such as stroke, brain tumour or surgery. Auditory processing disorder is the hearing equivalent of dyslexia where there is a normal pure tone audiogram but struggles to understand conversational speech.

Answer 57

Weber’s test is normal when both ears hear the same. In conductive loss it will be heard loudest in the affected ear and in sensorineural loss the opposite ear. Rinne’s test states that air conduction is greater than bone in normal ears and conductive hearing loss is when bone conduction is greater than air. (can also occur in sensorineural loss but rarely).

Answer 58

Pure tone audiogram is the gold standard test but it is subjective. Patients are asked to push a button when they hear a noise. Each ear is tested individually and there is bone vibrator attached to the headphones. The standard audio presented is adjusted to take into account the average thresholds at different frequencies. 20dB or better is normal hearing. The pure tone audiogram is then plotted. Whenever you see an abnormal response look at the BC and AC and ignore gaps of 10dB or less. If AC worse than BC by more than 10dB then conductive hearing loss at that frequency. If BC greater than 20bD there is sensorineural hearing loss. If BC >20dB and AC worse than BC by 10bD there is mixed hearing loss at that frequency. Pure tone average is the average threshold of hearing at 500Hz, 1KHx, 2 and 4 in each ear. This is a quick assessment for comparison between two ears. When fairly flat it is useful but asymmetrical is less useful. In presbycusis the graph will slope down as there is progressive worsening.

Answer 59

These will be a slightly different colour than the nasal septum, they are glistening and often pale/translucent yellow.

Answer 60

Rhinosinusitis is inflammation of the nose and paranasal sinuses characterised by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge. Other symptoms include facial pain/pressure and reduction or loss of smell. Endoscopic findings include polyp/middle meatal oedema or pus. CT evidence of mucosal disease affecting the osteo-meatal complex or inflammation of the paranasal sinus. Acute sinusitis lasts less than 12 weeks, is usually viral and will completely resolve. Recurrent acute rhinosinusitis is the same but more than 3 episodes in one year. Chronic rhinosinusitis is longer than 12 weeks (+/- nasal polyps) and will never completely resolve. Chronic rhinosinusitis affects 11% and is very strongly linked with respiratory problems. Asthmatics have an 80% chance of CRS, COPD 88% and patients with poorly controlled CRS have a 50% chance of developing asthma.

Answer 61

Initial management of CRS is saline nasal douching and intranasal corticosteroid spray such as fluticasone or mometasone because there is likely other steroid medications for respiratory illness. If this does not resolve in 4 weeks then there should be maximum medical therapy with a saline nasal douching, fluticasone propionate nasals 400mcg, and clarithromycin 250mg for three months (or doxycycline). If the patient has nasal polyps then they should have prednisolone, fluticasone propionate, saline douching and doxycycline 100mg for three months. Consider a different diagnosis if there is unilateral symptoms (malignancy), excessive crusting/bleeding (Vasculitis such as GwP) and immediately refer to hospital if there are orbital abscesses, evidence of cellulitis or intracranial infection (meningitis or intracerebral abscess). Surgery for CRS should be done if there was failure of maximal medical therapy. The surgical management aims to unblock normal sinus drainage pathways to facilitate future medical management. It is frequently required to manage orbital or intracranial manifestations. It is also useful in unilateral disease for obtaining a biopsy or removing a lesion.

Answer 62

Epistaxis can be life-threatening. Patient should sit upright with their head forward to facilitate spitting out of bleed. Pinch the nose at the bottom for 10 minutes. If this doesn’t work then examine nose, spray with topical anaesthesia or decongestant, if there is a visable vessel then it can be cauterised with silver nitrate, if posterior bleed then nasal packing can be done. Cannulate if not already done and get an FBC, U%E, clotting, G+S and LFTs. Consider tranexamic acid. Rapid Rhino packing create an internal balloon for pressure and an outer haemostatic gel coat. If nasal packing fails, then radiological embolization can be used for branches of the external carotid. Otherwise, surgery is needed such a ligation/cautery of sphenopalatine artery, anterior or posterior ethmoid arteries.

Answer 63

Nasal trauma should be assessed for other facial injuries such as orbital/zygoma fractures and hand fractures. Check for a septal haematoma (between perichondrium and cartilage of nasal septum). If septal haematoma is present then refer to ENT. Manage any epistaxis.

Answer 64

Ear: soft cartilage, narrow cartilaginous external ear canal and the length/width/direction of the estuation tube. The soft cartilage allows for easily manipulation of deformed pinna. The direction of the tube in children is upward and backwards whereas in adults it is downward and inferior. The shorter and narrower tube increases the risk of infection and glue ear. Nose: Children are obligate nasal breathers. There is also the presence of adenoids which enlarge infancy which can become problematic. The adenoid produce B-cells (IgG and IgA). Adenoidectomy might reduce serum IgG and IgA but does not reduce overall immunity. Adenoid enlargement can affect the estuation tube and cause stagnation of air. Enlarged adenoids can reduce the nasal airway and cause sleep disordered breathing or OSA. OSA is more likely if the tonsils are also enlarged. There is a peak incidence of 306 years and there is no difference with gender. Throat: Babies have a smaller jaw, no teeth, and a relatively larger tongue. The larynx is higher relative to other anatomical structures. Babies are not able to drink and breathe at the same time, but they have a high efficiency. Tonsils are graded in size. They drain into the jugulodigastric nodes and mi cervical nodes. Therefore, there is enlarged neck nodes with tonsillitis. The larynx is also funnel shaped in children with the narrowest part at the cricoid ring. Inflammation at the cricoid gives rise to croup. The cricothyroid space is poorly developed until roughly 12 years old so tracheotomy cannot be done. The larynx of children is much softer than in adults and thus there is increased likelihood of movement of walls with significant breathing efforts. This can be seen in Laryngomalacia and tracheomalacia which produces stridor with an URTI.

Answer 65

Acute otitis media is acute inflammation in the middle ear cleft and associated effusion. It presents with red bulging tympanic membrane, otalgia and pyrexia. The infection is usually self limiting but can be life-threatening (mastoiditis or intracranial sepsis). 40% are caused by viruses which need analgesia alone. If there is pain for more than 48 hours then it is likely bacterial and antibiotics can be considered. Common bacterial causes are H Influenzas, S pneumoniae and M catarrhalis. Recurrent AOM is more than 3 episodes in 6 months or 4 in 12. Treatment if not self-limiting is with prophylactic antibiotics or grommet insertion. Grommet insertion is not a cure but very effective.

Answer 66

Otitis media with effusion (glue ear) is very common with 5% of 5-year-olds. It is more common in winter and in those with allergic rhinitis and can follow AOM. Risks include artificial feeding, reflux, parental smoking, day care and genetics. It always happens in Down’s syndrome and common in those with cleft palate. Presents as painless hearing reduction with a retracted, opaque TM with fluid or bubbles. The glue is mucous. Investigations include a pure tone audiogram (bone air gap of 30dB) and tympanogram (flat trace because fluid under the TM is not compressible so will be flat reading). Treatment with grommet insertion works because the grommet acts as a ventilation tube. The risks include perforation, infections, discharge and damage. The alternative is hearing aids which is especially common in Down’s syndrome and Cleft palate. Otherwise grommet insertion can be considered if BC>AC by 25-30dB. Grommets allow drainage so there is increased discharge but less infections.

Answer 67

Tympanic membrane perforation commonly occurs following AOM. The child’s pain will suddenly improve alongside discharge. It can also occur as a complication of grommet insertion. Traumatic perforation (Barotrauma or cotton buds) usually occurs in the posterior tympanic membrane whereas AOM is anterior.

Answer 68

Mastoiditis is an infection in the middle ear which affects bone (Osteitis). There is usually pus, a pushed out ear, abscess behind the ear, signs of sepsis and there is the potential for intracranial abscesses.

Answer 69

Cholesteatoma is a mass formed of keratinising squamous epithelium in the middle ear cleft. They arise from retraction of the tympanic membrane which fills with keratin that cannot be shed. They are usually found in the attic of the ear and spread towards they mastoid. They are benign but can be very destructive. Congenital (intact TM) or acquired (Perforated TM). If untreated they will erode the bone and ossicles to produce conductive hearing loss and usually chronically inflamed hence chronic discharge. They can cause severe problems such as intracranial abscesses. Treatment is with mastoidectomy and surgery risks further hearing loss or imbalance and facial nerve injury and or chorda tympani (taste).

Answer 70

Tonsilitis is recurrent if there are 5 episodes per year for 2 years. They can be viral or bacterial and most commonly are caused by group A Strep. Tonsils should be removed if there is OSA, unilaterally enlarged (tumour) or quinsy. There is a risk of post operative bleeding and pain.

Answer 71

Adenoidal hypertrophy can cause OSA, runny nose and nasal obstruction. Adenotonsillectomy is an effective treatment but if fails CPAP may be required. Obesity is a cause of OSA in children and should be considered as a potential cause.

Answer 72

Foreign body are common and 1% fatal. Nasal foreign body blockages occur between 2-4 years most commonly and always beware of button battery. Inhaled FBs normally fall into the right main bronchus. On CXR there will be hyperinflation of the affected lung (air cannot escape) so the other lung appears radio-opaque. The mediastinum will be shifted away from the affected lung. Oesophagus obstruction presents with drooling. Nose aspiration into airway is very rare.

Answer 73

Septal Haematoma is more common in children and can become infected. They are caused by trauma. An infected septal haematoma requires surgical drainage urgently to prevent the loss of nose structural integrity.

Answer 74

Neck nodes are very common in children and often change size. A node is a concern if it is larger than 1.5cm for more than 6 weeks. Jugulodigastric are larger than other nodes. If they are tender, then there is likely inflammation. Other important features are weight loss, night sweats, fevers, cough. Mobile soft lumps are likely normal. USS and blood tests are standard but consider biopsy. Always have concern if there is a thyroid or supraclavicular mass.

Answer 75

Stridor (laryngomalacia, croup and acute epiglottitis) is noisy breathing which is more common in children due to narrow cricothyroid gap. When assessing stridor look for biphasic, opisthotonic posture, not feeding, sternal – intercostal recession, tiring and oximetry. Management is call for help, oxygen, nebulised adrenaline, steroids (Budesonide or Dexamethosone IV) and Heliox (20% o2 80% He). Laryngomalacia is the most common cause of stridor. It is an inspiratory stridor and is commonly associated with reflux. Surgery should be considered if there is failure to thrive or significantly increased WOB. They are usually spontaneously improving within 12-18 months. Croup is caused by Parainfluenza virus and presents with a barking cough. Commonly seen between 4 months and 2 years. Epiglottitis is caused by Haemophilus influenza, presents between 2-5 and there will be drooling.

Answer 76

Hearing loss in children can be congenital or acquired (sensorineural or conductive). Congenital deafness is usually sensorineural and can be autosomal dominant (Waardenburg, Branchio-oto-renal), autosomal recessive (Ushers, Pendreds or GJB2 mutations), X linked (Alports and Albinism) and mitochondrial. AR account for 75% and are the most serious. Aquired hearing loss are in the TORCH group (toxoplasmosis, rubella, CMV and Herpes simplex). These can cause fetal death. Meningitis, measles, encephalitis, chicken pox, head injury and ototoxic drugs can also cause hearing loss. Glue ear is a reversible cause of hearing loss. Risk factors include NICU>48hrs, family history, craniofacial involvement. Children should be regularly followed up after a positive Otoacoustic emission. All children should be reassessed for developmental and learning difficulties. Children with confirmed hearing loss should have a hearing aid by 6 months, if this doesn’t help then a cochlea implant by 12 months.

Answer 77

- Hard irregular, immobile neck node - Nodes larger than 2cm - Supraclavicular nodes - Thyroid mass - Stridor - FB, especially a battery - Postauricular swelling - Nasal obstruction following injury (septal haematoma) - Unilateral nasal discharge (suspect FB) - No speech by 2 years old (suspect poor hearing)

Answer 78

Any injury to the mid-face needs to have a visual acuity assessment which should be documented. Try to include a drawing. Numbness without a direct nerve injury is a fracture until proven otherwise. If teeth have been knocked out just put them back in the holes as a temporary measure. In facial trauma you should: - CT the face - Record visual acuity - Draw a diagram in the notes - Note lacerations and incised wounds mixed up - Feel the face and look in the mouth Skin injuries around the face are often a marker for underlying bone injuries. Contusion = grazes and abrasion = bruise. Laceration = blunt and incision = sharp. Lacerations are caused by blunt injuries and are associated with bruising. This is associated with poor healing.

Answer 79

Pulpitis (toothache) is a compartment syndrome which can cause severe pain. It will be spontaneous and poorly localised. Inflammation inside the tooth, generates pressure, generated ischaemia and hence pain. The only treatment is dentistry or a steroid powder in the cavity.

Answer 80

Peri-apical infection is an abscess above the tooth which follows the death of the pulp inside the tooth. There is often a preceding toothache. The pain is gradual onset and localised to the tooth.

Answer 81

Mid face fractures can be divided into cheek (malar, zygoma or ZMC), Naso-maxillary, Maxilla (Le Fort Fractures), Naso-ethmoid and orbital. Zygomatic maxillary complex (ZMC) fractures should be thought of as three fractures. Greater wing of the sphenoid, orbital floor and zygomatic arch. On X-ray there may be the eyebrow sign (dark line of air above the eyeball) which is indicative of a fracture. Naso-maxillary complex fractures should be suspected when there is difficulty breathing through the nose. An orbital blow-out fracture is when the thin orbital bones burst. This causes a rise of pressure inside the orbit and a pressure wave from impact on the orbital rim. Rene Le Fort fractures: (Maxilla fractures) Level 1: Teeth and alveolus have been knocked off the rest of the face Level 2: Nose and teeth have been knocked off the cheekbones Level 3: Whole face has been disarticulated Mandible fractures: The mandible often breaks at the point of impact and another break on the opposite side. If high energy impact; the bone will shatter. Signs of fracture include numbness, blood, dysfunction, deformity, pain where they were not hit, altered sensation, air where it should not be and poor mobility.

Answer 82

Airway compromise can be caused by dento-fascial space infections, dental sepsis and trauma such as gunshot wounds. Management is with ABCDE, leaning forward and calling for help.

Answer 83

Retro-bulbar Haemorrhage is a compartment syndrome. This is an emergency and failure to recognise it will lead to permanent blindness. This usually presents in elderly people on blood thinners. They will have a swollen eye and reduced visual acuity. Other key symptoms are pain behind the eye, proptosis (eye sticks out more than it should) and ophthalmoplegia (movement causes diplopia). Medical treatment is with IV steroids, Acetazolamide and Mannitol. This buys time for surgical decompression (lateral canthotomy).

Answer 84

White eye blow-out fracture can only occur between 12-20 because the sinus must be big enough for the orbital floor to burst and the bone springy enough to spring back on the orbital contents. This trapdoor action traps the eye muscles, and this requires urgent intervention. The patient will not have any bruising, but the eye will not be able to look up. Some will have nausea. It is called white eye blow out because there is no subconjunctival haemorrhage or bruising. If the muscle is not moved it will strangulate within 2 hours. The death of the inferior rectus muscle will cause permanent double vision. There is no need to organise CT scans, simply contact Max-Fax and Ophthalmology urgently. They may not have epistaxis, pain or loss of acuity so recognising is very important.

Answer 85

Avulsed tooth should always be put back in the hole. Tooth should be kept in an isotonic fluid such as milk. Consider referring to nearest dentist and remember missing teeth may have been pushed into other areas of the mouth.

Answer 86

Epidemiology: Head and neck cancer is the 8th most common cancer (4th in men) and incidence rates have risen. 46% oral cancer is preventable, and 73% laryngeal cancer is preventable. The major risk factors are tobacco and alcohol consumption. HPV is a significant cause of oropharyngeal cancer (HPV 16 which can be vaccinated against) whereas Epstein Barr virus has been associated with Nasopharyngeal cancer.

Answer 87

Leucoplakia is an idiopathic white patch in the oral cavity. White patches can be caused by friction (friction keratosis) which are not pre-malignant lesions. All leucoplakia is biopsied because some of these will have oral epithelial dysplasia which can progress to cellular atypia which are premalignant. Severe cellular atypia is a carcinoma in situ. Erythroplakia is a red patch in the oral cavity. These are more likely to be premalignant than leucoplakia and are often malignancy. If there are white and red patches, then they are speckled erythroplakia and they are highly suspicious. These should be removed. Oral Lichenoid lesions are caused by T-cell mediated inflammation driven by a metal filling or amalgam. Oral lichen planus (like the skin condition) can also be a cause. 1% will develop oral cancer. Peripheral verrucous leucoplakia is a white patch with a high malignancy rate. Chronic hyperplastic candidiasis in the buccal mucosa presents as white patches and there is a high rate of dysplasia. Other premalignant conditions include Fanconi anaemia, Ataxia telangiectasia, Blooms syndrome, Li-Fraumeni syndrome and immunosuppression (AIDS, Non-Hodgkin’s, and immunosuppressive therapy).

Answer 88

Symptoms include Leucoplakia, erythroplakia, persistent ulcers, pain, pain radiating to the ear, submucosal swelling, speech/swallow disturbance, enlarged lymph nodes (cervical) and cranial nerve involvement (X and XII).

Answer 89

obstruction, nasal discharge, blood-stained discharge, unilateral hearing loss and cervical lymphadenopathy.

Answer 90

Sore throat, sensation of foreign body, dysphonia, dysphagia, Odynophagia, pain referred to ear and cervical lymphadenopathy.

Answer 91

Hoarseness, swallowing difficulties, pain, cervical lymphadenopathy, and airway compromise.

Answer 92

Lump in gland, pain, facial nerve weakness, Hypoglossal/lingual nerve impairment, lump in mouth, cervical lymphadenopathy, and oropharyngeal mass.

Answer 93

Histology can be gained through excisional biopsy, fine needle aspirate or core biopsy. Histology is vital. The majority of head and neck cancers are SCC but not always. Imagine is with MRI for soft tissue and CT for bony areas. CT chest is vital because this is the main area for metastases. Ultrasound should be used for cervical lymphadenopathy to guide FNA. A PET CT should only be used if there is an unknown primary tumour site. Treatment is site specific and guided by the staging. The aim is microscopic clearance of disease with clear margins. Radiotherapy and surgery are the mainstay of treatment. The first 2 years are high risk for recurrence. Sentinel lymph node biopsy can be used as a staging mechanism and the presence of nodal involvement will escalate treatment to radiotherapy and/or chemotherapy. Radiotherapy can be considered a first line treatment for early cancers with adjuvant therapy. Surgery is the gold standard for oral cancer. Chemotherapy alone cannot cure head and neck cancer and is predominantly used as an adjuvant for locally advanced, recurrent, or metastatic disease. Cisplatin based chemotherapy. Cetuximab (biologic) can also be used.

Answer 94

Persistent conjunctivitis should always be assessed for chlamydia. Also consider corneal disease or blepharitis.

Answer 95

Cellulitis can be pre-septal or orbital. Pre-septal cellulitis is often associated with a lesion such as a chalazion or bite and the globe will be white. The vision is unaffected. This should be treated with broad spectrum antibiotics. Orbital cellulitis arises from the sinuses and the globe may be inflamed. Ocular movements are affected and there can be double vision. There will be optic nerve compression, optic disc swelling, and the vision is affected. This requires IV antibiotics, CT scan, sinus surgery and abscess draining. This is sight threatening and can be life threatening.

Answer 96

Corneal infection should be identified with fluorescein dye to identify defects in the epithelium such as ulcers or abrasions and the illuminate with a blue light. The light should be used to detect opacity and clinical features will help indicate the type of infection.

Answer 97

Corneal infection is uncommon and Neisseria gonococcus is one of the few bacteria which can cross an intact epithelium. The main causes of corneal infection are trauma (contact lens) and ocular surface or eyelid disease. The epithelium can regenerate and return to normal. The stroma heals with scarring and may vascularise, therefore central or peripheral lesions are an important distinction. Bacterial causes are staph, strep and gram-negative rods (pseudomonas which is very bad). Viral causes include adenoviruses and herpes, fungus (very rare), and protozoal (acanthamoeba is seen in contact lens wearers). A sample should be taken from the cornea for investigations. Ciprofloxacin and teicoplanin are first line antibiotics as eye drops. Dilating the pupil with cyclopentolate can help with pain relief. Steroid eye drops can be used if there is corneal opacification. If the cornea scars corneal transplant surgery may be required. Superficial peripheral scar may fade over time. There is a poor prognosis for corneal transplant surgery if there is vascularisation of the cornea or if the original infection was herpes.

Answer 98

Herpetic disease (simplex and zoster) presents with dendritic ulceration and stromal disease (Hazy cornea with intact epithelium). This should be treated with a topical antiviral, but a systemic antiviral may help in the acute phase and can prevent recurrence. Steroids can be used to treat corneal opacification. Even with the classic features of a dendritic ulcer a sample should be taken. Herpetic disease often damages the corneal sensory nerve and hence reduces sensation. Herpes zoster is very hard to manage. There can be corneal involvement, keratitis, elevated eye pressure, neuropathic cornea (no sensation) and post herpetic neuralgia. Systemic antivirals early on are beneficial. Steroid eye drops can be used for opacification.

Answer 99

Acute angle closure glaucoma is a medical emergency. Management is with Pilocarpine drops to constrict the pupil, IV acetazolamide, timolol eye drops and steroid eye drops. Laser iridotomy is the curative treatment which creates a whole in the iris to allow aqueous humour to flow out into the trabecular meshwork. It is more common is small eyes (especially cataractous as this enlarges the lens). The lens should be removed in these patients.

Answer 100

Retinal detachment is associated with myopia, direct trauma and acute posterior vitreous detachment. Posterior vitreous detachment is when the vitreous gel detaches which tears the retina. Fluid can then pass through the tear and the retina will detach. Vitreous degeneration and detachment cause floaters. If these floaters are accompanied by flashing lights then consider retinal detachment. Management is with surgical repair. If there is a retinal tear without detachment, then a laser or cryotherapy can be used to weld the retina in place. There are two types of detachment: Macula on and Macula off. Macula on is an urgent operation to preserve sight. Surgery relieves the traction, drains fluid away, pushes the retina into place and then welds it on with lasers or cryotherapy.

Answer 101

Retinal vascular occlusion can be arterial or venous. Arterial occlusion will have emboli (right) and a cherry red macula whereas venous will have signs of haemorrhage (left). There is no emergency treatment but lowering the intraocular pressure might help move an embolus. Identify systemic factors such as AF, Heart disease and diabetes. Retinal vein occlusion causes macular oedema and neovascular glaucoma. Macular oedema is treated with a macular laser and Anti0VEGF into the vitreous fluid. Neovascular glaucoma is extremely painful blindness and is caused by the ischaemic retina producing VGEF which stimulates new blood vessels to grow across the iris and block off the aqueous humour. Treatment is with anti-VEGF into the vitreous and laser to destroy the retina which is emitting the VEGF.

Answer 102

This would be treated like a TIA or stroke depending on the length of symptoms. Diagnosis is based on the history and examination findings.

Answer 103

Always differentiate between arteritic (GCA) and non-arteritic. Check the scalp and temporal arteries as well as asking for signs of jaw pain, unilateral headache, scalp tenderness, and symptoms of polymyalgia (Shoulder stiffness and weakness). Take ESR and CRP and refer. Arteritic ischaemic neuropathy will have a raised ESR and CRP and a doppler ultrasound should be conducted of the temporal arteries. Treatment is with IV methyl prednisolone and then oral steroids. Tapering can be guided by the symptoms and ESR.

Answer 104

Retinopathy, cataracts, neuropathy, infection and vascular disease.

Answer 105

In diabetic retinopathy there is leakage in the macula area which causes maculopathy. There is also occlusion which causes proliferation of new vessels and ischaemic maculopathy which is sight threatening. As DR worsens there is more ischaemia than leakage.

Answer 106

Type 1: Background DR has microaneurysms and dot/blot haemorrhages. (HMA) Type 2: Mild pre-proliferative DR has cotton wool spots and Type 3: Moderate pre-proliferative DR will have more than 6 cotton wool spots, small intra-retinal microvascular abnormalities and dense GMAs in 1-3 quadrants Type 4: Severe pre-proliferative DR has dense HMAs in 4 quadrants, multiple large intra-retinal miscrovascular abnormalities and venous bleeding in 2 quadrants Type 5: Proliferative DR has new vessels on the disc and fundus

Answer 107

Management is with avoidance (Screening and management of DM). Pre-proliferative and proliferative DR can be treated with retinal laser photocoagulation. Diabetic leakage maculopathy can be treated with a macular Laser, intravitreal anti-VGEF (Ranibizumab and aflibercept), intravitreal steroids and (Dexamethasone implant or Fluocinolone). If the maculopathy is caused by ischaemia then there is no treatment.

Answer 108

Hypertensive retinopathy is caused by malignant hypertension. This causes swelling of the optic disc, cotton wool exudates and a macular star (exudates centred on the macula or fovea). There is an association between hypertension and vascular disease which affect the eye such as retinal vein occlusion, artery occlusion and palsies of the nerves to the extraocular muscles.

Answer 109

Thyroid eye disease can cause site loss through corneal exposure and/or compressive optic neuropathy. It can also cause extra-ocular muscle malfunction causing double vision.

Answer 110

Uveitis, episcleritis and scleritis

Answer 111

Anterior Uveitis can be caused by non-infectious or infectious agents: Non-infectious: Behcet’s, Sarcoidosis, Arthropathy, WG, Lymphoma and idiopathic Infectious: Toxoplasmosis, TB, Syphilis, HSV, CMV, VZV, HIV and candida. There is a strong association with HLA B27 (Ankylosing spondylitis, psoriatic arthritis and IBD).

Answer 112

Symptoms are usually unilateral and include pain, photophobia, tenderness, redness and blurring. There is a tendency for the iris to stick onto the lens called posterior synechiae which means there are abnormally shaped pupils. Most cases are idiopathic and first episode is not usually investigated.

Answer 113

Complications include macula oedema, secondary glaucoma and cataracts. Treatment is with steroid eye drops, dilating drops (cyclopentolate or atropine), periorbital steroid injections (Sub-conjunctival dexamethasone) or oral steroids if there is macular oedema.

Answer 114

Posterior Uveitis presents with blurred vision, scotoma and floaters. Signs include vitreous haze, choroiditis (discrete pain lesions deep to retina), retinal vasculitis (perivascular infiltrates, white vessels, occlusion with distal haemorrhages) and retinitis. Visual loss is caused by macular oedema, ischaemia, cataracts, secondary glaucoma (inflammation or steroid use), optic nerve damage, secondary choroidal neovascularisation and retinal detachment. Non-infectious causes include sarcoidosis, Bechet’s disease, Wegener’s granulomatosis, ankylosing spondylitis, psoriasis and arthropathies. Infectious causes include toxoplasmosis which is caught from eating raw pork, owning three or kittens or being immunosuppressed. Treatment is with oral antibiotics and prednisolone. Viral causes include Herpes simplex, Varicella zoster, CMV and HIV.

Answer 115

Episcleritis presents with discomfort, localised redness, mild inflammation, unaffected vision, no underlying disease, resolves spontaneously and systemic NSAIDs or topical steroids may help

Answer 116

Scleritis presents with pain, diffuse redness, very inflamed, affected vision, underlying systemic disease, will progress to sign loss unless systemic steroids are provided.

Answer 117

Zone of coagulation: Primary site of damage with irreversible damage Zone of stasis: Secondary site of damage which will have impaired blood flow and so recovery is variable Zone of hyperemia: furthest from the site of injury and will have prominent vasodilation so usually recovers.

Answer 118

- Depth - Extent - Location - Age - Associated injury or disease The extent of a burn injury can be assessed by the Wallace rule of nines, Lund and Browder Chart or Palmar area. Initail A-F assessment: (primary survey)

Answer 119

A superficial burn affects the epidermis only. It is erythematous, hypersensitive and heals without a scar. This is seen in sunburn. Partial thickness burns involve the epidermis and part of the dermis. They can be superficial, middle, or deep. It will present with blisters, oedema, and erythema. They are very painful and there will be variable scaring. Full thickness burns can involve underlying muscle, tendon or bone and always involves the hypodermis. The lesion will be waxy white, leathery brown or charred black. They are painless and always heal with a scar.

Answer 120

Inhalation injury is an important determinant of mortality and morbidity. It manifests within the first five days after injury and occurs in 50% of admissions. 70% of deaths in burns units have inhalation injuries. Indications that an inhalation injury has occurred include burn in an enclosed space, facial or oral burns, singed nasal hair, soot in oral cavity, hoarseness, stridor, respiratory distress and signs of hypoxemia. There are three types of inhalation injury: Carbon monoxide poisoning, injury above glottis or below glottis. Management is with fluid resuscitation. This should be delivered through a large bore peripheral IV cannula. This should be achieved through the Parkland formula, crystalloid fluid is key, not colloid. In the first 24 hours there is hypovolemia, decreased CO and increased capillary permeability. In the second 24 hours the capillary permeability slowly returns to normal and colloid fluids should be used. This is only necessary in patients with burns larger than 30%. Colloid should be provided 0.5ml albumin x Kg x % burn. Urine output is a reliable guide of end organ perfusion and should be between 30-50 ml per hour in adults. Infusion rate should be adjusted accordingly. Blood pressure can be misleading because of progressive oedema and vasoconstriction. Tachycardia is often observed. Baseline serum chemistries and arterial blood gases should be obtained if larger than 30% TBSA.

Answer 121

The management of myoglobinuria/haemoglobinuria (seen in electrical and mechanical trauma) is to maintain urine output 75-100ml per hour. Add 12.5g Mannitol per litre.

Answer 122

If there is a circumferential burn of the extremity a Escharotomy should be considered. The patient’s rings and watches should be removed, limb elevated and hourly monitoring.

Answer 123

Electrical injury can be divided into high voltage (1000V) or low voltage. Hands and wrists are common entrance wounds and feet common exit wounds. They are difficult to clinically evaluate. Tissue damage occurs under and adjacent to contact points. Superficial tissue cools before deep tissue. A cutaneous burn without underlying tissue damage – no passage through patient A cutaneous burn with deep tissue damage – involvement of fat, fascia, muscle or bone Muscle damage with myoglobin release – Kidney damge with ‘port wine’ urine Management is with ABCs, assessment of injury, history, physical, Neuro, airway patency, and cardiac monitoring.

Answer 124

Burn debridement is a surgical procedure to remove necrotic burn tissue. The patient will require soft tissue reconstruction. Dressings ideally should be non-adherent, absorbent, antimicrobial/bacteriostatic and maintain some moisture at the wound.

Answer 125

Indications that an inhalation injury has occurred include burn in an enclosed space, facial or oral burns, singed nasal hair, soot in oral cavity, hoarseness, stridor, respiratory distress and signs of hypoxemia.

Answer 126

Fluid resuscitation is calculated on the TBSA and weight of the patient. Resuscitation is Parkland (crystalloid), Muir and Barclay (colloid) and hybrid. Urine output is aimed to be 0.5ml – 1ml/kg/hr and in children it should be between 1-2.

Answer 127

A full vision examination includes acuity, colour, field and pupil reactions. Visual acuity is measured using the Snellen Chart. This should be recorded without and with current glasses. This can be double checked by a pinhole occluder. If it improves then the glasses may need to be updated. Colour vision is measured via red desaturation with a simple red target (ischihara plates). Red desaturation is one eye at a time, red object will become orange in affected eye. This can be a subtle sign of optic neuropathy. Pupil reactions include direct, consensual and relative afferent pupil defect (asymmetry of the afferent visual pathway such as unilateral optic nerve disease). II and III nerve are tested in pupil reactions. Total afferent pupil defect is identified when light is shone into one eye, it constricts, the other eye, and then return to orginal eye and that eye dilates back to its resting state. Swinging eye tests needs to be horizontally done as the reflex is very quick. Legal requirement for driving is 6/12 vision on Snellen chart. Fluroscene drops are used for abrasions and scratches to the cornea and is often used in A&E. There is a risk of blurred vision (cannot drive after) and risk of angle closure glaucoma but the relative risk of missing an acute closure glaucoma is larger. They should be used for suspected posterior segment ocular problems. Snellen standardisation is 6m away. The denominator is the distance at which the average person can read the letter. Peripheral vision loss is caused by glaucoma, stoke of visual cortex or along visual pathway. A homogenous hemianopia is a stoke until proven otherwise. Temporal hemianopia is an optic chiasm lesion. This would also exclude driving until resolved. IOP is measured with tonometry. This can be measured via contact (applanation) or non-contact (air puff).

Answer 128

Cataracts Non-surgical: initially stronger glasses and brighter lighting are all that is required. Surgical treatment is curative and should be considered depending on the impact on the quality of life. There are potential risks such as posterior capsule opacification (thickening of the lens capsule), retinal detachment, posterior capsule rupture and endophthalmitis (inflammation of aqueous or vitreous humour). Cataract surgery should be offered to anyone who wants it and are fit enough ot have surgery. Cataract surgery limitations include risk of inflammation, infection, bleeding, swelling, drooping eyelid, dislocation of artificial lens, retinal detachment, glaucoma, secondary cataracts and loss of vision. Mild discomfort post-surgery. Not everyone will have vision successfully restored.

Answer 129

Cherry red spot on pale retina

Answer 130

Fundus fluorescein angiography for normal choroidal filling with delayed or absent filling of the central retinal artery. Systemic evaluation. Carotid artery duplex (ophthalmic artery is branch or carotid), non-contrast CT head or MRI. Cardiac assessment may also be required if carotid disease is ruled out. This could be GCA

Answer 131

This is a medical emergency and so referral for stroke evaluation is essential to minimize risk of secondary ischaemic events (MI). Retinal blood flow should be restored within 90 mins. Options include Mannitol, acetazolamide, sublingal isosorbide dinitrate or IV methylprednisolone. Surgical options include anterior chamber paracentesis, ocular massage, laser embolectomy, and pars plana vitrectomy. Post-recovery lifestyle changes should be made to optimise reduction of atherosclerotic disease.

Answer 132

Pain, vomiting, nausea, headache, halo sign, reduced vision, unilateral/bilateral, Hx of hyperopia, medications (SSRIs), and timing

Answer 133

Flat is caused by fluid (glue ear), perforation and grommits Left peaking is caused by eustation tube dysfunction

Answer 134

Prophylactic antibiotics (low dose trimethoprim), surgery with grommet insertion. Cholesteatoma often needs surgery with mastoid exploration.

Answer 135

TORCH, meningitis, measles, chicken pox, ototoxic drugs (gentamicin), genetic conditions, encephalitis, and head trauma. AR genetics account for 75% of congenital conditions.

Answer 136

Investigations: FBC (WBCs), U&Es (baseline before Abx), CRP, Lactate (sepsis indicator), blood cultures and consider a lumbar puncture if intra-cranial extension is suspected. CT temporal bones required which will show loss of distinctive air cell wall due to atrophy/necrosis of the bony septa, mastoid air cell and middle ear opacification due to fluid collection and inflammatory mucosal swelling, distortion of the mastoid outline and enhancement of areas of abscess formation. An MR venogram may be performed if lateral sinus thrombosis is suspected. Low ferritin can be found in sepsis. There is also an increased risk of thrombosis because of the inflammatory markers. This is an emergency and thus ABCDE. Initiation of Sepsis 6 and IV antibiotics, surgical nil-by-mouth, ENT referral, analgesia, cross-sectional imaging and consider lumbar puncture. IV Cefotaxime or metronidazole is most common. Surgical management is with tympanocentesis, myringotomy (+/- grommet/ventilation/tympanostomy insertion) and cortical mastoidectomy. Purulent middle ear fluid should be sent to microscopy. Once recovered a pure-tone audiometry should be done.

Answer 137

Over 90% of head and neck cancers are SCC and over 50% are preventable. 70% occur between 50-75 years old. Risk factors include smoking, alcohol, HPV (only oropharynx) and pollution.

Answer 138

When describing a head and neck cancer: Site, size, adjacent/involved structures and appearance. There are often rolled margins, speckled appearance, contact bleeding, ulceration, induration and/or fixation in oral cancer. Larynx cancer presents as a mass with an irregular appearance and are friable.

Answer 139

Differentials include lymphoma, sarcoma, metastases, TB, lipoma, other benign lesions or amyloidosis. Drug-induced ulcers are seen in Nicorandil. Poor dentition may cause sharp teeth and thus ulcer may just be caused by trauma.

Answer 140

Surgical: Lazer ablation, excision, lymph node dissection or neck dissection and reconstructive plastic surgery Radiation: External beam radiation therapy (Intensity modulated radiation therapy or proton therapy). Others: Chemotherapy, immunotherapy, and targeted therapy (EGFR inhibitors) Long term side effects of radiation therapy are dry mouth (common) and osteonecrosis.

Answer 141

Vocal chord palsy, GORD, neurological impairment, and psychological issues

Answer 142

Dizziness: Light headedness or disorientation (children may fall over) Vertigo: A sensation of spinning Balance: A sensation of falling or loss of posture

Answer 143

Semi-circular canals measure horizontal and vertical movement (rotational motion). Disorders of the semi-circular canals cause the sensation that the patient is spinning. Inertia is feeling the opposite of the movement (plane goes forward pushing up back into our seats). The Maculae consists of the saccule and utricle, and they detect liner motion such as forwards and backwards. They also act as gravity detectors. There are three semi-circular canals (Posterior, horizontal, and superior). The utricle and saccule are responsible for movement in the linear plans whereas the semi-circular canals detect movement rotationally. There are three reflexes: Vestibulocular (fix on objects when head moves), vestibulocollic (Stabilises head when torso moves) and Vestibulospinal reflex (Stabilises in trips and falls).

Answer 144

Benign paroxysmal positional vertigo is caused by movement of otoliths from the otolithic membrane in the utricle which disrupts the hair cells in the semi-circular canals. The brain interprets this as a rotation motion despite a small movement. Clinical test is with Dix-Hallpike and treatment is with Epley manoeuvre. There is the potential for a brainstem tumour for these symptoms and they will not respond to multiple Epley treatments. Look up head thrust test for direct vestibular impairment. Also Benign paroxysmal vertigo of childhood.

Answer 145

There are three inputs into the balance system: Vision, proprioception, and vestibular labyrinth (equilibrium, spatial awareness, rotation and linear movement). The brain can compensate when one is affected but two or more is problematic.

Answer 146

If a patient presents with acute onset vertigo you must differentiate between peripheral vestibular disorders and posterior circulation infarction.

Answer 147

Vestibular neuronitis/Labyrinthitis presents with acute onset vertigo which is associated with nausea. Vertigo increases with head movement and can be very debilitating. Labyrinthitis will also have hearing loss. It will last for several days followed by a period of imbalance. Treatment is supportive followed by vestibular rehabilitation if imbalance persists. They may initial require antiemetics.

Answer 148

Meniere’s disease is caused by endolymphatic hydrops which is characterised by episodes of vertigo associated with hearing loss, tinnitus, and aural fullness. The episodes can last between 20min and 24hours. Conservative management is dietary modification with reducing salt intake. Medical is betahistine or antidiuretics and surgery is with ablative procedures such as intratympanic gentamicin.

Answer 149

Vestibular migraine is usually seen in patients with a history of migraine or family history. Vertigo/imbalance may occur without the headache symptom. They may also have associated motion sickness. Duration can be from minutes to hours and treatment is with migraine medication and vestibular rehab.

Answer 150

The patient must inform the DVLA if their symptoms of vertigo are sudden, disabling, or recurrent.

Answer 151

Allergic rhinitis is an IgE mediated inflammation of the nasal mucosa following exposure and sensitisation to an allergen. They can be seasonal, perennial, transient, or persistent. Common causes include grass pollen, tree pollen, Cat/Dog and house dust mites.

Answer 152

Medicamentosa is caused by overuse of nasal corticosteroids which causes rebound inflammation. If there is a watery discharge with allergic rhinitis and recent nasal surgery, consider a CSF leak.

Answer 153

Symptoms of allergic rhinitis are blocked/stuffy nose, watery discharge, itch, associated eye/skin/chest symptoms and blocked ear. On examination, there may be an inflamed inferior turbinate, red mucosa, not much space and watery discharge. There may also be redness externally and around the eyes.

Answer 154

Allergic rhinitis is a clinical diagnosis, but RAST IgE blood test can be done for common respiratory allergens and skin prick testing (but this requires coming of antihistamines for two weeks).

Answer 155

Treatment is with allergen avoidance, saltwater rinse 4x a day, oral or topical antihistamines and steroid nasal sprays. Refractory cases require allergy testing, oral steroids, turbinate reduction surgery and consideration of alternative diagnosis. Immunotherapy and De-sensitisation can be done by an immunologist.

Answer 156

Conductive hearing loss is up to the Stapes’ footplate and sensorineural is anything beyond this. Left is usually blue, and right is red (R for R). Masking is used to ensure bone and air conduction are tested separately. Right is circular and blue is an X. Normal hearing: Hear quiet sounds of less than 20dBHL Mild hearing loss: Hearing loss between 20-40dBHL Moderate hearing loss: 41-70 Severe: 71-95 Profound hearing loss: Over 95 If some BCs are within 10dB of the ACs but others are not then it is a mixed hearing loss.

Answer 157

Haemangioma, dermoid cysts, thyroglossal cysts, branchial cysts and vascular malformations.

Answer 158

Reactive node, atypical mycobacterium, TB and abscesses

Answer 159

Lymphoma, thyroid tumour, pilomatrixoma, salivary gland tumours and metastatic lesions.

Answer 160

Cervical lymphadenopathy can be caused by viruses such as adenovirus, parvovirus, RSV, rhinovirus and EBV. Common bacterial causes are staph aureus and Group A Strep. Rarer causes include Bartonella, Atypical Mycobacterium, TB, Lymphoma, SLE, RA and Kawasaki’s disease. Extremely rare causes include CMV, HIV, Rubella, Mumps, Varicella, Leukaemia, Toxoplasmosis, vaccines, phenytoin and Isonaziad.

Answer 161

When examining get a size, site, mobility, fixation, tenderness, redness, warmth and matting (a bad sign). A normal lymph node is less than 1.5cm, mobile, soft and vary in size with colds. Red flags are hard, irregular, immobile, larger than 2cm, any supraclavicular node or thyroid mass. If there is a red flag, then a FBC and CXR should be done as well as examination for hepatosplenomegaly and petechiae. If a node is larger than 3cm or present for more than 4 weeks, then consider a biopsy.

Answer 162

Thyroglossal cysts are found in the midline and are common. They are caused by an embryonic abnormality. Usually in children under ten and identified as a soft neck lump with protrusion of the tongue. USS should be used to ensure normal thyroid tissue is present before continuing to surgical options.

Answer 163

Dermoid cysts can present anywhere along the line of embryonic closure and are also common. They are formed through the inclusion of epithelial cells and contain both epidermal and mesodermal elements. This can lead to the Prescence of hair, teeth and sebaceous glands. Half are present at birth and most others present by the age of 5. They do not move on swallowing or protrusion of the tongue. They are treated with surgical excision.

Answer 164

Branchial cysts are congenital abnormalities most commonly seen in the second branchial arch. They present with a pit or swelling in the mid or lower neck at the anterior border of the sternocleidomastoid muscle. They should be removed surgically.

Answer 165

Haemangiomas/vascular malformations: Haemangiomas present up to 6 weeks after birth, rapidly proliferate endothelium and then spontaneously resolve by 10 years old. They can present anywhere in the head and neck and should be managed conservatively unless there is airwat compromise. Vascular malformation will not involute and will grow with the child, they are present form birth. Cystic hygromas (lymphatic malformations) are most common and present as a soft, transilluminating neck mass and should be treated with surgery or sclerotherapy.

Answer 166

Lateral neck lumps are usually branchial cysts, haemangiomas, vascular malformations or teratomas (extremely rare). Midline neck lumps are usually thyroglossal cysts, dermoid cysts or thyroid lumps

Answer 167

Most tumours of salivary glands are benign. Branchial cysts can be found in adult and commonly following an infection. Thyroid nodules are much more common in adults and especially women. They require TFTs, USS and thorough history and examination. Carotid body tumours are masses that are present at bifurcations of the carotid artery. They are a form of paraganglioma and require USS and MRI scan. Enlarged lymph nodes with no relation to infection require investigation. B-symptoms are more suggestive of a lymphoma. Investigation include USS and core biopsy. An excision biopsy can also be performed under a local anaesthetic. Always rule out SCC before assessing for lymphoma. Lymphoma is treated with chemotherapy by the haematologists. Head and neck cancer can be treated medically (radiotherapy and chemotherapy) or surgical removal. Submandibular duct stones cause lumps which enlarge with eating, usually parotid.

Answer 168

Hypothyroidism is a condition in which the thyroid gland produces insufficient thyroid hormone for the body’s requirements. Causes include autoimmune thyroid disease (Hashimoto’s), radioactive iodine, surgery and drugs (Lithium carbonate and sulphonamides). Symptoms include weight gain, lethargy, depression, hair loss, bradycardia, diastolic hypertension, constipation, menstrual disorders, cognitive impairment, voice changes, dry skin and goitre. Treatment is with thyroxine replacement.

Answer 169

Hyperthyroidism is a condition in which the thyroid gland produces excess thyroid hormone. Causes include autoimmune thyroid disease (Graves), thyroiditis and thyroid nodules. Less common include over use of thyroid medication, amiodarone or dietary iodine. Symptoms include anxiety, tremor, proximal muscle weakness, goitre, heat intolerance, clammy hands, exophthalmos, weight loss, hair loss, hypertension, widened pulse pressure, palpitations, tachycardia, AF, amenorrhoea, oligomenorrhea and thyroid storm. Treatment is with antithyroid drugs (Carbimazole or propylthiouracil), beta blockers, radioiodine therapy and surgery.

Answer 170

Thyroid storm is a medical emergency which can be triggered by surgery, pregnancy, sepsis and cardiovascular events. This can cause death through cardiovascular collapse. This requires ITU admission.

Answer 171

Newborns are obligate nasal breathers and thus nasal obstruction should be treated with saltwater drops. Unilateral causes include a foreign body, choanal atresia, adenoids and deflected septum Bilateral causes include choanal atresia, adenoids, and allergy. Congenital causes are cystic fibrosis, choanal atresia and masses. Acquired include infections, foreign bodies, enlarged adenoids, nasal polyps and mucocele. A unilateral nasal discharge in a child should be considered a foreign body until proven otherwise and if battery must be removed urgently.

Answer 172

Rhinosinusitis is defined as inflammation of the nose and the paranasal sinuses characterised by two or more symptoms. One must be nasal blockage/obstruction/congestion or nasal discharge (anterior or posterior drip). Other symptoms can include facial pain/pressure, reduction of smell. On endoscope there may be nasal polyps, mucopurulent discharge, or oedema/mucosal obstruction. Acute is sudden onset lasting less than 12 weeks whereas chronic is over 12 weeks. Acute bacterial rhinosinusitis is suggested by 3 of: - Discoloured discharge - Severe Local Pain - Fever (38+) - Elevated ESR/CRP - Double sickening (deterioration after an initial milder phase of illness) Management: Symptomatic relief: Decongestants (short course), analgesia, saline irrigation and self care. Topical steroids (flixonase/Avamys – Fluticasone based sprays or drops). Antibiotics. Biological treatments and immunological desensitisation spray. Surgery can be used for chronic rhinosinusitis. It is not a cure but can help with symptomatic relief.

Answer 173

Glue ear (Otitis media with effusion), TM perforation, infection, disarticulation of the ossicle (trauma or cholesteatoma) and otosclerosis (older children).

Answer 174

There is a spectrum from simple snoring, sleep disorder breathing and then Obstructive Sleep Apnoea. The most common causes of OSA in children are adenotonsillar hypertrophy (3-6), obesity and congenital abnormalities (trisomy 21 and craniofacial abnormalities such as Pfieffer syndrome). Pathophysiology: REM sleep causes reduced muscle tone. This is worse for children with enlarged adenoids or obesity. In later life this can cause neurobehavioral problems and pulmonary hypertension.

Answer 175

OSA is defined as recurrent events of partial or complete upper airway obstruction during sleep, resulting in disruption of normal ventilation and sleep patterns, neurocognitive deficits, and cardiovascular co-morbidities. 12% are habitual snorers whereas 0.7% have OSA. OSA can be severe, moderate or mild. Central apnoea is neurological and so surgery will not improve their symptoms.

Answer 176

In the history, daytime and night-time symptoms should be investigated. Night-time symptoms include nocturnal enuresis, sweating, disturbed sleep, snoring, restlessness, and strange positions. Daytime symptoms include hyperactive or somnolence, irritability, and aggression. Examine the palatine tonsil, grade between 1-4. Grading is quarterly so 1 = 0-25% oropharynx and 4 is kissing tonsils (75-100%). Examine for lymphadenopathy, nose, and ear. Cold spatula under the nose for misting is important. Bilateral otitis effusion is associated with enlarged adenoids. Assess BMI. Investigations are not usually conducted but pulse oximetry or polysomnography may be beneficial. Naso-endoscopy may only be tolerated by older children. Management is with Adenotonsillectomy which is curative in 83% but there are associated risks. Weight loss for those with a high BMI, CPAP, nasal steroids and Orthognathic/Craniofacial surgery may also be indicated.

Answer 177

Usual antibiotics are amoxicillin or azithromycin, and ciprofloxacin ear drops are the topical treatment of choice.

Answer 178

Stridor is high pitched noise originating from lower airway (Larynx or Trachea) whereas Stertor is a low-pitched noise originating from the upper airway (Nasopharynx or Oropharynx).

Answer 179

The most common reason for stridor is laryngomalacia which will present within the first few weeks of life. It has an inspiratory stridor which is worse on feeding and crying and can cause failure to thrive. In the majority of children it will spontaneously resolve but some may require surgical intervention if there is failure to thrive or sleep. Subglottic stenosis can be congenital or acquired and can present with recurrent croup or stridor and may require a tracheotomy before surgical correction. Subglottic Haemangiomas/cysts can also cause stridor. Vocal cord palsy can be unilateral or bilateral. It can be congenital or caused by cardiothoracic surgery. The palsy narrows the airway and can present as an emergency. Foreign bodies.

Answer 180

This is a rare genetic disorder that causes: C – Coloboma of the eye H – Heart defects A – Atresia of the nasal choanae R – Retardation of growth G – Genital/Urinary abnormalities

Answer 181

Choanal atresia is a congenital disorder where the nasal choanae is blocked by abnormally soft bony tissue die to a failed hole development of the nasal fossa during prenatal development. It presents with persistent rhinorrhoea, and if bilateral there will be cyanosis and hypoxia as children are obligate nasal breathers.

Answer 182

The skulls bones gradually fuse, and early fusion determines the abnormal head shape depending on which sutures fuse. Most deformities are non-syndromic. A normal head shape is wide and round at the back, high at the back, narrows and lowers at the front, flat at the front and vertex above bregma.

Answer 183

Trigonocephaly is a triangle shaped head deformity caused by Metopic suture fusion. The eyes are too close together (hypotelorism) and 40% will have expressive speech delay. Raised ICP is very rare.

Answer 184

Scaphocephaly is a boat shaped head caused by premature fusion of the sagittal synostosis. This is non-syndromic and 40% have expressive speech delay. 20% have raised ICP.

Answer 185

Unicoronal Craniosynostosis is a trapezium shaped head with the eye drawn up on the affected side. The Forehead is pulled back and there will be nasal deviation with the tip away from the affected side. It is usually non-syndromic. There may be facial scoliosis (abnormal face curvature).

Answer 186

Positional Plagiocephaly is a normal variant whereby the child has a parallelogram shaped head. This is normal at birth and will slowly improve. 50% are born with this and it does not require intervention. There is no risk of raised ICP.

Answer 187

Syndromic Craniosynostosis is commonly bi-coronal or complex multisutural. Head shapes can be very unusual including Turricephaly (tower shaped), Brachycephalic (short AP) or cloverleaf shaped. It is associated with Chiari malformations, hydrocephalus and raised ICP. Aperts is usually bi-coronal or multi-suture and present with mid-face hypoplasia. They may have mitten hands and developmental delay is common. This is an Autosomal Dominant condition. Crouzons syndrome is common. It is bi-coronal and presents with mid-face hypoplasia and developmental delay is normal. However, they will have normal hands, unlike Alperts. Other syndromes include Pfeiffers, Saethre-Chotzen, Muenke, Carpenters, Beara-Stevenson, and many others.

Answer 188

Cleft lips are a gap in the upper lip which can involve the gum. It can be unilateral or bilateral. They can be lip-incomplete or extend to the nose. They are caused by failure of fusion of the facial prominences (medial nasal prominence to maxillary prominence) which occurs between 5 and 7 weeks in utero. More common in boys. Left side is most commonly affected.

Answer 189

Cleft palates are a gap in the palate which can involve the soft palate, hard palate or both. It occurs due to failure of elevation and fusion of the palatal shelves. This occurs between 8 and 10 weeks in utero. This is more common in females.

Answer 190

Cleft lip and palate is a gap involving the lip and palate which always goes through the gum. This can be unilateral or bilateral. This occur 1/700 births. Most common in Chinese ethnicity and least in Afro-Caribbean. Clefting is a threshold disease where there is a combination of genetics and environmental factors. Environmental factors include anti-convulsant, smoking, alcohol, folate deficiency, corticosteroids, maternal diabetes, retinoic acid and warfarin.

Answer 191

Treatment pathway: 1. Diagnosis antenatal or postnatal 2. 3-5 months lip/nose/hard palate repair 3. 6-9 months soft palate repair +/- grommets 4. Speech assessment at 18months and 3 years 5. Secondary speech surgery if needed 6. 8-10 years pre-bone graft orthodontics 7. 9-11 years bone graft 8. 11+ definitive orthodontics 9. 16+ secondary surgery for maxilla and mandible or nose

Answer 192

Recurrent oral ulceration occurs in 20% and presents with recurring oral ulcers with no underlying systemic problems. Aphthous-like ulcers occur with underlying systemic disease. Causes include nutritional deficiencies (B12, folate, ferritin), coeliac, Immunodeficiency (HIV), IBDs, and Behcet’s syndrome. Triggers for ulceration in susceptible patients include stress, smoking, fluctuations in hormones and trauma. Management is investigating underlying causes, tailor to severity of the disease, symptomatic relief with Lidocaine spray, difflam mouthwas/spray. Gengigal mouthwash, Chlorhexidine mouthwash or barrier ointments such as orabase paste. Topical corticosteroids can be used such as betamethasone soluble tablets. Systemic agents can only be used in secondary care and include colchicine and prednisolone.

Answer 193

Lichen planus is an autoimmune, chronic inflammatory condition which can affect the skin, oral mucosa, nails, ano-genital mucosa and the scalp. Very rarely it is seen in oesophageal, larynx and conjunctiva. In the mouth there can be reticular oral lichen planus on the buccal mucosa with the classic Wickham’s striae. Biopsy is required for diagnosis. There are many potential appearances of LP in the mouth and can be red and white. Symptoms of oral lichen planus include rough feeling, pain with spicy/citrus foods, SLS toothpaste causing irritation and irritation with mint. OLP is a potentially malignant condition with 1% developing head and neck cancer. Requires dental follow up. Asymptomatic cases can be reassured and monitored. Symptomatic cases require intervention. Treatment is with immunosuppressants such as methotrexate. Lichenoid reaction (not LP) can be seen with ACE-inhibitors, NSAIDs, oral hypoglycaemics, Gold salts, anti-malarial and Carbamazepine. Amalgam/Mercury fillings can also cause a lichenoid reaction. Graft vs Host disease and Lupus can imitate LP.

Answer 194

Oral Candidiasis is usually an opportunistic infection and most cases are caused by candida albicans. There are many variants in presentation, post antibiotics you may see acute pseudomembranous candidiasis. Angular cheilitis presents around the corners of the mouth. Chronic plaque-type candidiasis is a pre-malignant lesion and requires biopsy. Underlying causes can be HIV, smoking, dentures, diabetes, steroid inhalers, dry mouth and use of topical steroids. Management is to treat the underlying cause. Fluconazole 100mg OD PO for 14 days. Nystatin or Miconazole can also be used as topical agents.

Answer 195

Dry Mouth (Xerostomia) is the subjective feeling of dry mouth with or without hyposalivation. It is important to establish the underlying diagnosis. Causes include, Xerogenic medications, Caffiene, alcohol, smoking, radiotherapy to head and neck, diabetes, dehydration, autoimmune disease (Sjogren’s), Sarcoidosis and anxiety. Patients will report dryness, difficulty eating, speaking and burning sensation or chronic sore throat and the need to carry a lot of water. They are suspectable to candida infections which causes the burning sensation. On examination there will be dry lips/cracking, smooth depapillated tongue, dental erosion and caries. There may also be visible food debris and the tongue can stick to the palate. Management is to investigate the underlying cause, use fluoride toothpaste, saliva replacements (BooXtra gel or spray), Saliva stimulants (SSTs, Salivix Pastilles, chewing gum) and Secretagogues (pilocarpine).

Answer 196

A mucocele on the upper lip is malignant until proven otherwise.

Answer 197

Dental Caries are caused by high sugar intake and poor dental hygiene. Oral bacteria use dietary sugars to produce acids which cause the decay. The acids dissolve the teeth and form cavities. Once bacteria reach the pulp they will cause pulpitis. Toothache can be pulpitis and the pain is caused by a closed environment oedema. If they attend ED then this is likely irreversible. Pain is often poorly localised, exacerbated by heat and relieved by cold temperatures. This should be managed with root canal or extracted. There is no indication for antibiotics.

Answer 198

Apical Periodontitis is another form of toothache which is an early dental abscess. The pulp undergoes necrosis, and the body is unable to eradicate the bacteria. Bacteria then project out into the surrounding bone. The pain is well localised and tender to pressure. The tooth socket may be raised and there will NOT be any signs of swelling or oedema. This is more common in immunocompromised and diabetics. It requires root canal or extraction, and antibiotics can be required.

Answer 199

An acute apical abscess is a dental condition in which there is a localized bacterial infection at the tip of a tooth's root, often resulting from untreated dental decay or trauma. The abscess is characterized by symptoms such as severe toothache, swelling of the gums and face, fever, and difficulty opening the mouth. Treatment usually involves draining the abscess and prescribing antibiotics to control the infection, followed by definitive treatment of the underlying dental problem, such as a root canal or tooth extraction. If left untreated, an acute apical abscess can lead to complications such as the spread of infection to other parts of the body. Acute apical abscess is a well-formed abscess that presents with fluctuant swelling or even cellulitis. It can tract back into the facial regions. This is a medical emergency. Red flags are drooling, tachycardia, SOB, can’t lie back or struggling to talk. IV antibiotics, incision and drainage is required. Antibiotics are usually metronidazole and amoxicillin.

Answer 200

Gum disease (Periodontal disease) is non-resolving inflammation due to plaque. The main risk factors are smoking, and diabetes and it is generally a chronic condition. It may present as a dental abscess, bleeding gums or mobility of the teeth. They may require antibiotics if there is systemic involvement. General management is conservative.

Answer 201

Transient Visual loss is mainly caused by migraine, retinal artery emboli, ischaemic optic neuropathy and post-chiasmal vascular disease (TIA). Rarer causes include acute glaucoma, raised ICP and optic neuritis. Amaurosis fugax is fleeting blindness which usually occurs unilaterally and is caused by poor retinal circulation. Whereas a TIA is a transient stroke and thus a cerebral event. Associated symptoms to ask about in an ophthalmic history include aura, headache, eye pain, haloes, eye redness, nausea and vomiting and jaw claudication. Hyperopic people are prone to acute angle glaucoma. Visual obscurations are seen in optic neuritis and papilledema. Non arteritic ischaemic optic neuropathy is caused by GCA. PMH should investigate systemic vascular disease, polymyalgia rheumatica (GCA), smoking and family history. GCA presents with transient visual loss with headache on the same side. It is associated with polymyalgia, malaise, weight loss and jaw claudication. There will be an elevated CRP and ESR.

Answer 202

Floaters are naturally occurring opacities in the vitreous gel. Concerning floaters are sudden in onset, associated with flashing light, net curtain or cobweb appearance and can present like a shower or tadpole. These are signs of posterior vitreous detachment. This pulls on the retina causing a tear which can lead to detachment. People who are short sighted are more likely to have retinal tears. Direct ocular trauma and previous eye surgery are higher risk for retinal detachment. Other causes of floaters are Vitreous Haemorrhage and retinal vein occlusion (consider diabetes and diabetic retinopathy). Inflammatory and neoplastic causes are extremely rare. Always consider migraine, ocular ischaemia, hallucinations, and Charles Bonnet Syndrome (hallucinations in blindness).

Answer 203

Corneal ulcers present with redness on the eyeball with opacity in the cornea. They should be stained with fluorescein. They can present with pain and altered vision. Dendritic branching ulcers are seen in herpes simplex ulcers.

Answer 204

Iritis/Anterior Uveitis presents with redness of the eyeball, pain, and disturbed vision. The pupil may be small or irregular and there can be associated systemic conditions (HLA B27).

Surgery C Flashcards

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