Magnetic resonance imaging brain and orbits Pituitary tumour, compressive lesion
Carotid Doppler ultrasound Carotid artery stenosis in ocular ischaemic syndrome
Lumbar puncture Idiopathic intracranial hypertension, inflammatory orbital neuropathies
Temporal artery biopsy Giant cell arteritis
OSCE example 1: Gradual visual loss
Please examine this patient’s eyes
• Introduce yourself and clean your hands.
• Assess visual acuity using a Snellen chart at the appropriate distance.
• Examine the eyes, looking for any conjunctival injection, chemosis or swelling.
• Test the pupillary light reflexes.
• Ideally, dilate the pupils at this stage.
• Test the red reflex in each eye.
• Dial the fundoscope to +10 and examine the anterior portion of the eye, including the lens.
• Finally, inspect the macula.
• Thank the patient and clean your hands.
The most likely diagnosis is diabetic maculopathy.
Suggest initial investigations
Urine dipstick, fasting blood glucose and blood pressure.
Please examine the patient’s eye movements
• Introduce yourself and clean your hands.
• Inspect visual acuity for each eye.
• Test pupillary light reflexes.
• Test all eye movements for ophthalmoplegia.
• Examine the optic nerve using an ophthalmoscope.
• Examine cranial nerves I, V, VI, VII, VIII, IX, X, XI and XII.
• Thank the patient and clean your hands.
Double vision is confirmed on testing of eye movements.
aneurysm cause a dilated pupil, which responds poorly or is completely unresponsive to light.
Integrated examination sequence for ophthalmology
• Introduce yourself and clean your hands.
• Explain what you will be doing.
• Observe the patient as they walk into the room, looking for:
• Gait (may indicate a possible cerebrovascular accident).
• Check visual acuity in each eye for distance and near vision.
• Undertake an assessment of the visual fields:
• Look for homonymous hemianopia, bitemporal hemianopia or any other obvious visual field defect.
• Assess direct and consensual reflex.
• Dilate both pupils using tropicamide 1% eye drops.
• Examine each eye using the direct ophthalmoscope:
• Focus on the optic disc: look at colour, shape and cupping, as well as swelling.
• Examine the blood vessel arcades in each quadrant.
• Ask patient to look up, down, right and left so that you can examine the peripheral retina.
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Common presenting symptoms 173
Testing vestibular function 178
Common presenting symptoms 180
Common presenting symptoms 184
OSCE example 1: Hoarseness 190
Integrated examination sequence for ear, nose and throat disease 191
172 • The ear, nose and throat
clearly. The outer portion of the canal has hair, and glands that
produce ear wax, which forms a protective barrier.
The middle ear is an air-filled space that contains the three
bony, articulated ossicles: the malleus, incus and stapes. The
Eustachian tube opens into the middle ear inferiorly and allows
equalisation of pressure and ventilation. Vibrations of the tympanic
membrane are transmitted and amplified through the ossicular
chain and focused on to the smaller oval window on which the
stapes sits (Fig. 9.1B). The malleus is attached to the tympanic
membrane and can be seen clearly on otoscopy (Fig. 9.2). The
long process of the incus can also be visible occasionally. The
tympanic membrane has a flaccid upper part (pars flaccida) and
it is important to look carefully in this area, as this is where a
The ear is the specialised sensory organ of hearing and balance.
It is divided anatomically into the external, middle and inner ear.
The external ear consists of the cartilaginous pinna, the external
auditory canal (cartilage in the lateral one-third, bone in the
medial two-thirds) and the lateral surface of the tympanic
membrane (Fig. 9.1). Sound is collected and channelled by
the pinna and transmitted via the external auditory canal to
the tympanic membrane. The external auditory canal has an
elongated S-shaped curve; hence it is important to retract the
pinna when examining the ear to see the tympanic membrane
Fig. 9.1 The ear. A The pinna. B Cross-section of the outer, middle and inner ear.
of the VIII nerve or cochlea (Box 9.2). Profound loss before speech
acquisition affects speech development and quality.
Tinnitus is an awareness of a noise in the absence of an external
• quality of tinnitus: high-pitched, ringing, pulsatile
• intermittent or constant nature
• whether it is unilateral or bilateral
• associated hearing loss or other ear symptoms.
cholesteatoma (an invasive collection of keratinising squamous
epithelium) can form. The chorda tympani nerve runs through
the middle ear carrying taste fibres from the anterior two-thirds
of the tongue; these ‘hitch a ride’ with the facial nerve, which
runs through the mastoid bone in the wall of the middle ear.
The inner ear contains the organs of hearing (cochlea) and balance
(vestibular system). The vibration of the stapes footplate stimulates
fluid within the cochlea. This results in the movement of hair cells
in the cochlea, which are converted to electrical impulses along
the vestibulocochlear nerve (VIII).
The vestibular system helps maintain balance, along with
visual input and proprioception. The vestibular part of the inner
• The lateral, superior and posterior semicircular canals:
these lie at right angles to detect rotational motion of their
fluid (endolymph) in three planes.
• The utricle and the saccule: their hair cells are embedded
in a gel layer containing small crystals (otoliths), which are
subject to gravity and enable detection of head tilt and
• preceding trauma, upper respiratory tract infection (URTI)
• associated symptoms: dysphagia/voice change
(suggesting possible referred pain from a throat lesion).
Otalgia (ear pain) associated with pruritus (itching) is often
due to otitis externa. Acute otitis media is common in children
and otalgia often follows an URTI. Other causes of otalgia are
• purulent, mucoid or blood-stained discharge (otorrhoea)
A purulent discharge can be caused by otitis externa or acute
otitis media with a perforation. A chronic offensive discharge
may be a sign of cholesteatoma.
Blood-stained discharge may suggest the presence of
granulation tissue from infection or can be a result of trauma,
with or without an associated cerebrospinal fluid (CSF) leak.
• precipitating factors: trauma, URTI, noise exposure,
• impact of the hearing loss on the patient’s function.
Hearing loss can be due to disruption in the conduction
mechanism or may have sensorineural causes, such as failure
9.1 Causes and features of earache (otalgia)
Acute otitis externa Pain worse on touching outer ear, tragus
Purulent discharge and itching
Acute otitis media Severe pain, red, bulging tympanic
membrane, purulent discharge if tympanic
Perichondritis Erythematous, swollen pinna
Trauma Pinna haematoma, pinna laceration,
haemotympanum (blood behind tympanic
membrane); cerebrospinal fluid leak or
facial nerve palsy may be present
Vesicles in ear canal, facial nerve palsy
may be present; vertigo is common
Malignancy Mass in ear canal or on pinna
Sore throat, tonsil inflammation
Trismus, soft-palate swelling in peritonsillar
Tenderness, clicking of joint on jaw opening
Dental disease Toothache, e.g. due to dental abscess
Cervical spine disease Neck pain/tenderness
Associated sore throat, hoarseness,
dysphagia, weight loss, neck lump
• Chronic middle ear infection
• Prenatal infection, e.g. rubella
Disruption to the mechanical transfer of sound in the outer ear, eardrum or
174 • The ear, nose and throat
• associated headaches, nausea or aura (migraine)
• previous significant head injury; previous URTI.
The most common causes of vertigo include benign paroxysmal
positional vertigo (attributed to debris within the posterior
semicircular canal), vestibular neuritis (also known as vestibular
neuronitis, a viral or postviral inflammatory disorder) and Ménière’s
disease (caused by excess endolymphatic fluid pressure). Other
causes include migraine, cerebral ischaemia, drugs and head
trauma. Discriminating features are described in Box 9.3.
Nystagmus is an involuntary rhythmic oscillation of the eyes,
which can be horizontal, vertical, rotatory or multidirectional. It
may be continuous or paroxysmal, or evoked by manœuvres
such as gaze or head position. The most common form, ‘jerk
nystagmus’, consists of alternating phases of a slow drift in one
direction with a corrective saccadic ‘jerk’ in the opposite direction.
The direction of the fast jerk is used to define the direction of
nystagmus (Box 9.4). Pendular nystagmus, in which there is
a sinusoidal oscillation without a fast phase, is less common.
Nystagmus may be caused by disorders of the vestibular, visual
Tinnitus is usually associated with hearing loss. An acoustic
neuroma (a tumour of the vestibulocochlear nerve, cranial nerve
VIII) needs to be considered in unilateral tinnitus or tinnitus with
an asymmetrical sensorineural hearing loss.
Vertigo is a sensation of movement relative to one’s surroundings.
Rotational movements are most common and patients often have
associated nausea, vomiting and postural or gait instability. Vertigo
can originate peripherally or, less often, centrally (brainstem,
cerebellum). Patients will often say they are ‘dizzy’ when describing
the illusion of movement: that is, vertigo. It is very important to
clarify exactly what they mean by this. Lightheadedness is not
a vestibular symptom, but unsteadiness may be.
• duration and frequency of episodes
• aggravating or provoking factors (position, head
• associated ‘fullness in the ear’ during the episode
• associated focal neurology (cerebrovascular event)
• fluctuating hearing loss or tinnitus
positional vertigo Vestibular neuritis Ménière’s disease
Central vertigo (migraine, MS,
Duration Seconds Days Hours Hours – migraine
Long-term – cerebrovascular accident
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