HEENT

A 68-year-old man presents to the emergency department with sudden painless loss of vision in his right eye that began 45 minutes ago while watching television. His history includes hypertension, hyperlipidaemia, atrial fibrillation (not anticoagulated due to a fall six months ago) and a 30-pack-year smoking history. He denies headache, scalp tenderness, jaw claudication or eye pain. Observations are BP 158/94 mmHg, HR 88 bpm irregularly irregular, temperature 36.7°C, SpO2 98% on room air. Visual acuity is hand movements only in the right eye and 6/6 in the left. Examination reveals a right relative afferent pupillary defect. Fundoscopy of the right eye shows a pale, oedematous retina with a cherry-red spot at the macula; the left fundus is normal. There is no temporal artery tenderness. What is the most appropriate immediate management?

A 52-year-old woman presents to the emergency department with a 2-hour history of severe rotational vertigo associated with nausea and vomiting. She reports this is her fourth similar episode in the past 8 months, each lasting between 20 minutes and several hours. She describes a sensation of fullness and roaring tinnitus in her left ear, and her partner has noticed that her hearing on that side seems to fluctuate, worsening during attacks. She has no fever, headache, focal neurological symptoms or recent viral illness. On examination she is afebrile, heart rate 96 bpm, blood pressure 128/78 mmHg, and appears distressed with horizontal spontaneous nystagmus beating away from the affected ear. Gait is unsteady but she is able to walk with support. Cranial nerve examination is otherwise normal, HINTS testing is consistent with a peripheral vestibular lesion, and otoscopy is unremarkable. Audiometry from a previous ENT review confirmed low-frequency sensorineural hearing loss on the left. Given a diagnosis of an acute attack of Meniere's disease, what is the most appropriate acute management?

A 30-year-old contact lens wearer presents to the emergency department with a 3-day history of a painful red right eye. He reports using tap water to rinse his lenses and often showers and swims while wearing them. On examination there is marked photophobia and blepharospasm, with pain that appears disproportionate to the relatively mild degree of conjunctival injection and corneal haze seen on slit-lamp examination. Visual acuity is reduced to 6/12 in the affected eye. There is no hypopyon, and fluorescein staining shows a faint epithelial irregularity without a discrete dendritic pattern. Vital signs are normal. Which of the following is the most important diagnosis to consider in this patient?

A 30-year-old woman with a 15-year history of moderate persistent asthma presents to the emergency department with progressive bilateral nasal blockage and complete loss of sense of smell over the past 12 months. She describes several episodes of acute, severe bronchospasm after taking ibuprofen for headaches, requiring nebulised salbutamol on each occasion. She denies fever, purulent discharge or facial pain. Observations are: HR 88 bpm, BP 122/76 mmHg, RR 18/min, SpO2 97% on room air, afebrile. On examination she has mild expiratory wheeze bilaterally. Anterior rhinoscopy reveals pale, oedematous, glistening polypoid masses filling both nasal cavities, with no mucopurulent discharge. There is no periorbital swelling, proptosis or cranial nerve deficit. Which of the following represents the most appropriate next step in management?

A 58-year-old man is reviewed on the ward five days after starting intravenous gentamicin for Pseudomonas aeruginosa bacteraemia complicating a diabetic foot infection. He reports that his surroundings appear to 'jump' whenever he moves his head (oscillopsia) and describes marked unsteadiness that is worse in the dark or when walking on uneven ground. He denies vertigo at rest, tinnitus or hearing loss. Observations are unremarkable and there is no fever. On examination, nystagmus is absent, but the bedside head impulse test demonstrates bilateral corrective saccades, and he is unable to read a wall chart while gently shaking his head (positive dynamic visual acuity test). Romberg's test is positive. Renal function has been mildly impaired throughout admission, and gentamicin trough levels have been at the upper end of the therapeutic range. What is the most appropriate next step in management?

A 72-year-old woman presents to the emergency department with a two-week history of temporal headache, scalp tenderness on combing her hair, and jaw pain that worsens with chewing. Over the past two hours she has developed sudden, painless loss of vision in her right eye, now reduced to perception of light only. She reports malaise, low-grade fevers and a 3 kg weight loss over the past month. On examination her right temporal artery is thickened, tender and non-pulsatile. Fundoscopy of the right eye shows a pale, swollen optic disc with flame haemorrhages. Observations are stable. Blood tests reveal ESR 100 mm/hr and CRP 80 mg/L. What is the most appropriate immediate management?