SBA 8

SBA 8

Dermatology, ENT, Ophthalmology

Atopic eczema

common, chronic, inflammatory skin condition that presents as a poorly demarcated, itchy red rash

Atopic eczema

• It typically affects the skin folds, especially in elbows and behind knees, although in more severe cases it can occur almost anywhere on the body.

• It is a/w atopic traits, such as asthma, hay fever and allergic rhinitis.

• Most cases present before age of 5. It affects up to 30% of children and about 10% of adults.

Causes of atopic eczema

• Genetic - FH of atopy

• Irritants - detergents, dish washer

• Allergens or environmental problem - cold and dry weather, pollen, dust

• Food allergies

• Skin infection

Pathology

• Reduced barrier effectiveness - due to lack of Filaggrin (protein involved in creation of barrier), causing environmental potential allergens to permeate the barrier and reach the deeper skin cells below

• Immune response - Once allergens have permeated the barrier, there is an exaggerated IgE mediated immune response to the allergens.

Diagnosis of atopic eczema

• Itchy skin + 3 or more of the following

• 1. Onset below age of 2

• 2. Visible flexural dermatitis

• 3. Past history of flexural dermatitis (or dermatitis on cheeks and/or extensor areas in children aged 18 months or under)

• 4. Past history of dry skin in last 12 months

• 5. Past history of asthma or allergic rhinitis (or history of atopic disease in a 1st degree relative of children aged under 4 years)

Severity of atopic eczema

Treatment

Management can then be stepped up or down, according to the severity of symptoms

Emollients - basis of atopic eczema management and should always be used, even when eczema is clear. 

Ophthalmology

Loss of vision and red eyes

Loss of vision

blue = painless

red = with pain

Retinal detachment

• Sudden painless loss of vision - Preceded by flashing lights or floaters due to abnormal retinal stimulation prior to detachment

• Classically – ‘like a curtain falling down over my vision’

• Causes : myopia, DM, trauma, cataract surgery, retinopathy of prematurity

• Examination – visual field loss, afferent pupil defect, grey retina which may balloon forwards

• Refer urgently

Retinal detachment

Macula involved = Central vision loss

Macula NOT involved = peripheral field loss and visual acuity maybe normal 

Glaucoma

Glaucoma is classified into 2

1. Acute glaucoma (closed angle)

2. Chronic glaucome (open-angle)

Normally, aqueous fluid fills both anterior and posterior chamber and is drained out of the eye via irido-corneal angle in anterior chamber. The aqueous humour filters back into the blood and circulation through the trabecular meshwork. 

Pressure is therefore maintained by a balance between aqueous production and drainage.

Acute angle closure glaucoma

• MEDICAL EMERGENCY !!

• Angle becomes narrowed (“closed”) and it is this narrowing that prevents aqueous from flowing correctly into the trabecular meshwork.

• Blockage of aqueous drainage from the anterior chamber causes build up of aqueous fluid and a sudden increase in intraocular pressure

Acute glaucoma - Epidemiology

• 0.1% of patient >40 yo - typically elderly

• long sighted women with early cataract

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Acute glaucoma - Presentation

• Extremely red and painful eye often a/w NV

• Acute visual loss in one eye

• Episodic haloes around bright lights

• Headache

• Eyeball feels hard, cornea looks hazy

Acute glaucoma - Treatment

• Decrease eye pressure QUICKLY – many treatments at once

• Topical B-blockers (Timolol) – decrease aqueous production

• Carbonic anhydrase inhibitor (Acetazolamide) – decreases aqueous production

• Miotic (pilocarpine) – constrict pupil to open outflow angle

• Surgery

Chronic glaucoma (open angle)

• More common than acute glaucoma

• The angle is not affected, but instead there is a defect of the trabecular meshwork which slows down the flow of aqueous humour

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Chronic glaucoma - Presentation

• In early disease – often no signs or symptoms

• Often detected during routine examination

• Visual acuity is preserved until visual fields is severely impaired

• Examination shows elevated pressure, optic disc changes, visual loss (peripheral)

• Central vision is usually normal

Chronic glaucoma - risk factors

• Increase intraocular pressure

• FM x10 risks

• Elderly

• African Americans

• Abnormal BP

• Myopia

Chronic glaucoma - treatment

• Treat the underlying risk factors

• Medical 

  Topical β-blockers – decrease aqueous production at ciliary body Prostaglandin analogues – increase aqueous humour outflow

• Surgical

Diabetic retinopathy

• May occur if blood glucose control is poor

• 3 stages - non-proliferating, pre-proliferating and proliferating

• Non-proliferating - Microaneurysm, hemorrhage, hard exudates (Leaking from arterioles) --> Normal vision

• Pre-proliferating (retinal ischemia) - cotton wool spots (infarct), hemorrhage, venous beading --> gradual reduction in vision

• Proliferating - new vessel formation --> reduction in vision

Diabetic retinopathy - Presentation

• Most patient are asymptomatic.

• Haemorrhages may cause acute onset dark spots (‘floaters’). Severe haemorrhage may cause visual loss. Haemorrhages are painless.

Slit Lamp findings

• Microanueysm – due to weakness in capillary wall

• Hard exudates – collections of proteins that congregate on retinal surface

• Cotton wool spots – ‘fluffy’ patches on retina

• Haemorrhages – from weakened capillaries (appear larger than micoaneurysm)

• Neovascularisation – an attempt by retina to heal

Hypertensive retinopathy

• High BP damages retinal vessels

• Grading of hypertensive retinopathy

• 1. Tortuous arteries with thick shiny walls (silver wiring) - hardened arteries

• 2. AV nipping (narrowing where arteries crosses veins)

• 3. Flame hemorrhages and cotton wool spots - narrowed arterioles become blocked, causing central retinal infarction

• 4. Papilloedema

Multiple Choice

Bethany is a 40-year-old woman who presents with a red eye and significant nausea. She has noticed that her left eye was red when she woke up from sleep. She also has a concurrent headache with this and her vision is blurry. When asked, she feels that she can see rings around lights as well. She remains otherwise well.

Examination reveals significant conjunctival injection around the left eye. The pupil appears to be dilated at 5mm and does not respond to light. Her right eye has a pupil size of 3mm and is reactive to light.

What is the likely cause for her symptoms?

• Anterior uveitis

• Acute angle closure glaucoma

• Posterior uveitis

• Chronic glaucoma

• Cluster headache

Explanation - B

• Acute glaucoma typically presents as acute red eye a/w sudden visual loss. The eye will be painful to movement and appearance of halos around light is also seen.

• Anterior uveitis is a diagnostic possibility and can also present as an acutely red eye with visual loss. It is not commonly a/w visual halos.

• Posterior uveitis is usually painless and common symptoms include blurry vision and floaters. It does not cause a red eye.

• Cluster headaches should not be a/w any pupillary defects. 

• Primary open-angle glaucoma does not typically present acutely. Most cases are asymptomatic.

Multiple Choice

This diabetic man complained of worsening of his vision. What is seen on fundoscopy?

• Normal retina

• Central retinal vein occlusion

• Proliferative retinopathy

• Macular oedema

• Papilloedema

Multiple Choice

A 65-year-old man presents with an acute, painful red eye. Which one of the following features would not support a diagnosis of acute angle closure glaucoma?

• Vomiting

• Patient sees haloes around light

• Dull cornea

• Small pupil

• Decreased visual acuity

Multiple Choice

Which one of the following features is not present in diabetic pre-proliferative retinopathy?

• Microaneurysms

• Blot hemorrhages

• Cotton wool spots

• Venous bleeding

• Neovascularisation

Multiple Choice

A 63-year-old gentleman is diagnosed with primary open angle glaucoma. He asks how untreated glaucoma is most likely to affect vision?

• Impairs color vision, with red color vision affected first

• Impairs central vision

• Impairs peripheral visual fields

• Impaired visual acuity

• Impairs night vision

Explanation - C

• Glaucoma causes an optic neuropathy, that most frequently affects patients visual field. This tends to commence in the peripheries, and if untreated, eventually leads to tunnel vision.

• Visual acuity can be affected, but this is less common.

ENT

What is this?

• Normal ear

• the cone of light is located in the 5 o’clock position when viewing a normal right tympanic membrane and in the 7 o’clock position for a normal left tympanic membrane

What is this?

• Otitis externa

• Inflammation of ear canal

• Often known as 'swimmer's ear'

What is this?

Otitis Media with effusion

Otitis Media

• Self-limiting infection that mainly affects children

• Can be caused by bacteria or virus

• Symptoms last for 3 to 7 days

• Complications such as developmental delay, speech delay, learning difficulties

• Complications such as mastoiditis is rare

NICE otitis media

• Explain that it is self-limiting and advice for self-care

• Safety netting (3 days) and back-up antibiotics prescription can be given

• Paracetamol and NSAIDs are given for pain control

• Refer to hospital if there is severe systemic infection or complications e.g. mastoiditis, intracranial abscess, meningitis, sinus thrombosis or facial palsy

Choice of antibiotics

• Amoxicillin 125-500mg TDS 5-7days

• Clarithromycin BD or erythromycin QID if penicillin allergy

• Second line - Co-amoxiclav TDS

What is this?

• Grommet

• Usually falls off itself in 6-12 months

• Can be used in chronic otitis media

What is this?

Trauma, ear perforation

What is this?

• Impacted ear wax

• Might cause hearing loss and misdiagnosed with other diseases such as Meniere's disease

• Irrigation, Manual removal (suction) and Topical preparations (sodium bicarbonate, cerumol) can be used

What is this?

Cholesteatoma

Chronic infection

Vertigo

What is this?

Tympanosclerosis

What is this?

• Ramsay Hunt syndrome

• Herpes zoster infection in facial nerve

• Facial palsy, vesicular rash

• Ear pain, hearing loss, tinnitus

• Aciclovir 800mg 5 times daily for 7 days

Multiple Choice

A 62-year-old man with a 3 month history of dizziness when he rolls over in bed. Episodes last for about 20 seconds

• Benign paroxysmal positional vertigo (BPPV)

• Meniere's Disease

• Acute labyrinthitis

• Vestibular neuronitis

Multiple Choice

A 51-year-old female with a 3 week history of recurrent attacks of vertigo, right ear tinnitus and the sensation of fullness in her right ear. On testing, there is noted to be right-sided hearing loss affecting low frequencies.

• BPPV

• Meniere's Disease

• Acute labyrinthitis

• Vestibular neuronitis

Multiple Choice

A 33-year-old with coryzal symptoms presents with a one day history of vertigo and nausea. There is no hearing loss on examination

• BPPV

• Meniere's Disease

• Acute labyrinthitis

• Vestibular neuronitis

Explanation of vertigo

• BPPV - chronic without hearing loss

• Meniere's - chronic with hearing loss

• Vestibular neuronitis - acute without hearing loss

• Acute labyrinthitis - acute with hearing loss

• Acoustic neuroma - tinnitus + hearing loss + facial palsy

• Cerebellar tumour - Dysdiadochokinesia, increased ICP, ataxia

Multiple Choice

A 30-year-old woman who presents with a three week history of bilateral nasal obstruction, cough at night and a clear nasal discharge. She had similar symptoms around this time last year and the only history of note is asthma. What is the most likely diagnosis?

• Allergic rhinitis

• Chronic sinusitis

• Nasal polyps

• Acute sinusitis

• Asthma

Explanation - A

• History of asthma and symptoms occur same time last year suggests allergic rhinitis.

• Clear nasal discharge also points to non-infection

Management of allergic rhinitis

• Avoid allergen

• Oral or intranasal antihistamines

• Intranasal corticosteroids

Sinusitis

• Symptoms is similar to allergic rhinitis

• Might have symptoms of infection such as fever and headache

• Discolored nasal discharge

• Usually lasts for 7-10 days

• 4 weeks - acute, >12 weeks - chronic

NICE sinusitis

• Do not offer antibiotics unless people presenting at any time who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high risk of complications

• Explain that sinusitis is self-limiting which last for 2-3 weeks, advice for self-care

• Safety netting if not improved in 3 weeks

• Consider high dose nasal corticosteroid for 14 days for patient aged 12 years old and over who presented with sinusitis for more than 10 days

Choice of antibiotics

• Phenoxymethylpenicillin 500mg QID 5days

• Co-amoxiclav 500/125mg TDS 5days if systemically unwell

• Doxycycline, clarithromycin or erythromycin if penicillin allergy

• Lower doses for pediatrics patients

Multiple Choice

A 17-year-old woman presents to her GP after noticing a painless neck lump.

On examination there is a 2cm x 1cm anterior midline neck swelling that is smooth and cystic in nature. The lump moves upwards with protrusion of the tongue. There are no other significant clinical findings.

Which of the following is the most likely diagnosis?

• Thyroid adenoma

• Thyroid cyst

• Swollen lymph node

• Lymphoma

• Foreign body

Explanation - B

• Thyroid cyst moves in both swallowing test and tongue protuding

• Thyroid mass might only moves in swallowing test but not tongue protuding

• Painful neck lump might suggest swollen lymph nodes which indicates infection

• Lymphoma presented with numbers of painless swollen lymph nodes, fever, weight loss