Chapter 13 - Eye, Ear, Nose, and Throat Disorders Flashcards
1
Q
Sinusitis pathophysiology
A
- Bacterial is most common cause for the acute care setting
- Undrained collection of pus occurs in the sinuses
- Frequently proceeded by insult to sinuses (i.e., viral URI, allergic rhinitis, nasal instrumentation)
- Occurs more frequently in patients with anatomical abnormalities
2
Q
Sinusitis common pathogens
A
- Strep. pneumoniae (Gram+) [most common bacterial cause]
- H. influenzae (Gram-) [most common among smokers]
- Moraxella catarrhalis (Gram-)
- Consider pseudomonas species in ventilated patients
3
Q
Sinusitis symptoms
A
- Headache at its worst when the head is dependent
- Stuffy nose
- Pressure behind eyes
4
Q
Sinusitis diagnostics
A
- CT scan is diagnostic study of choice when one is required
- However – diagnosis is usually clinical
5
Q
Sinusitis treatment
A
- Antibiotics, typically empiric
- First-line: amoxicillin-clavulanate (Augmentin) 500/125mg PO TID or 875/125 mg BID
- Second-line (or if allergic to PCNs): doxycycline 100 mg PO BID or 200 mg PO daily
6
Q
Conjunctivitis etiology/pathophysiology
A
- Inflammation of the conjunctiva caused by bacteria, virus, or allergies
- No matter the cause, there is a high risk of bacterial infection secondary to how fragile the conjunctiva is
- Always treat bacterial pathogens prophylactically (because of conjunctival fragility)
7
Q
Conjunctivitis common pathogens
A
- Viral pathogens (most common) – adenovirus, herpes simplex
- Bacterial pathogens – staph (MRSA), strep pneumoniae, H. influenzae, gonococcal, chlamydial
8
Q
Conjunctivitis symptoms/exam findings
A
- Common symptoms – pruritus, foreign body sensation, “gritty eye”
- Pain is almost never a symptom
- Conjunctival erythema, conjunctival injection, ocular discharge (consistent with etiology of infection)
9
Q
Conjunctivitis – viral etiology specific symptoms and treatment
A
- May present unilateral or bilateral (typically will start unilateral and spread bilaterally)
- Watery discharge
- Consider prophylactic antibiotics (because of fragile conjunctiva)
- Symptomatic treatment – artificial tears, topical antihistamines, cold compresses
- Discontinue contact use
10
Q
Conjunctivitis – bacterial etiology specific symptoms and treatment
A
- Typically will start unilateral (may spread bilaterally)
- Purulent discharge
- Gonococcal/chlamydial = PROFUSE discharge, eyelid edema, refer to ophthalmology
- Bacterial treatment – gentamycin 1-2 gtt daily x1 week, ciprofloxacin 1-2 gtts QID x1 week (good for contact wearers)
- Gonococcal/chlamydial treatment – refer to ophthalmology; ceftriaxone 1g IM once + azithromycin 1 g once
- Discontinue contact use
11
Q
Conjunctivitis – allergic etiology specific symptoms and treatment
A
- Typically noted around times of high seasonal allergies
- Presentation is typically bilateral
- Stringy discharge with itching
- Decongestants, antihistamines (oral or topical), cold compresses, discontinue contact use
12
Q
Corneal abrasion – common causes
A
- Scratch
- Flying debris
- Dry eyes
- Iatrogenic
13
Q
Corneal abrasion – symptoms/physical exam findings
A
- Gradual throbbing pain that intensifies over 12-24 hours
- Sensation of foreign body
- Erythema
- Tearing
- Interrupted endothelial surface on fluorescein stain
14
Q
Corneal abrasion – diagnostics
A
- Fluorescein stain
- Clinical diagnosis
- Orbital CT or MRI if high velocity injury or retained foreign body suspected
15
Q
Corneal abrasion – treatments
A
- Initial anesthesia of the eye (tetracaine)
- Topical NSAID drops – diclofenac or ketorolac
- Topical antibiotics – must cover for bacteria – bacitracin, cipro
- Oral opiate (1 day prescription should be enough)
- Tetanus shot if penetrating injury
- Refer to ophthalmology if no improvement in 48 hours or initial presentation is severe
- Do not order – corticosteroid drops, eye patching, continued use of topical anesthetic
16
Q
Glaucoma cause (chronic [open] vs. acute [narrow])
A
- Chronic – elevated pressure reduces flow to of aqueous humor → GRADUAL rise in pressure
- Acute – variety of anatomic abnormalities resulting in reduced flow of aqueous humor, acute blockage of flow → ACUTE rise in pressure
17
Q
Glaucoma symptoms – (chronic [open] vs. acute [narrow])
A
- Chronic – gradual, PAINLESS loss of peripheral vision, usually asymtpmatic until discovered on routine screening. Rarely symptomatic – may present with ocular discomfort, halos, or blurry vision
- Acute – SEVERE ocular pain, SUDDEN vision loss, halos around objects
18
Q
Glaucoma physical exam findings – (chronic [open] vs. acute [narrow])
A
- Chronic – elevated intraocular pressure (not as high as acute), gross physical exam can be normal
- Acute – decreased visual acuity, sclera injection, firm globe, IOP severely elevated (normal: 10-20 mmHg)
19
Q
Glaucoma treatment – chronic (open-angle)
A
- Medications aim to reduce pressure by either improving flow or reducing production of aqueous humor
- Prostaglandin analogues (first line) (-prost) – latanoprost (Xalatan)
- Can also give beta-adrenergic antagonists (beta blockers) – do not give if contraindicated (i.e., heart blocks, uncontrolled respiratory disease) because of systemic absorption
- Refer to ophthalmology
20
Q
Glaucoma treatment – acute (wide-angle)
A
- Treat as emergency
- Systemic carbonic anhydrate inhibitors – acetazolamide (Diamox) 500 mg IV once followed by 250 mg PO QID – watch for Na abnormalities and metabolic acidosis
- Topical beta blockade (Timolol 1 drop to affected eye)
- Refer to ophthalmology
- Definitive treatment = laser iridotomy
21
Q
Otitis Media – common causes
A
- Streptococcus
- H. influenza
- M. catarrahlis
22
Q
Otitis media – symptoms/exam findings
A
- Decreased hearing
- Otalgia
- Fever
- Aural pressure
- Erythematous TM
23
Q
Otitis media – treatment
A
- Duration of 5-7 days
- No other antibiotics – amoxicillin/clavulanate (Augmentin)
- On other antibiotics – amoxicillin 500 mg TID or 875 mg BID; macrolide (azithromycin, clarithromycin)
- If chronic/recurrent – refer to ENT
24
Q
Pharyngitis – causes
A
- Viral
* Group A beta-hemolytic streptococci
25
Pharyngitis – symptoms/exam findings
* Sore throat
* Dysphagia
* Rhinorrhea (viral)
* Fever (bacterial)
* Erythematous pharynx
* Exudate (bacterial)
26
Pharyngitis – diagnostics
• Can do GABHS rapid antigen test or throat culture
27
Pharyngitis – treatment
* Viral – analgesics + supportive measure (i.e., gargle salt water)
* Bacterial (GABHS) – penicillin VK 500 mg BID x10 days or macrolide of PCN allergy (azithromycin, clarithromycin)
28
A 33-year-old male is admitted to the ICU secondary to traumatic injury. While evaluating the patient the day after his admission, he complains of bilateral eye discomfort. The patient states he wears contact lenses and only removes them every 2 weeks when he changes them. A physical exam is significant for serous discharge, reddened conjunctivae, and irregular shapes on both corneas. What is the most likely diagnosis?
a. Corneal ulcers
b. Dacryocystitis
c. Conjunctivitis
d. Uveitis
a. Corneal ulcers
A is correct because: bilateral eye discomfort and irregular cornea shape are consistent with corneal ulcers
B is incorrect because: dacryocysitits is infection of the lacrimal sac and is not consistent with this presentation
D is incorrect because: uveitis is inflammation of the uvea and is not consistent with this presentation
29
Use the following scenario for questions #2 and #3. A 40-year-old female patients presents to the trauma unit after suffering a physical assault. She was hit in the head and chest multiple times with a wooden bat. On physical exam, you note multiple areas of facial swelling and appreciate the following finding: *picture - bilateral black eyes*. You suspect multiple facial fractures and determine the patient’s airway is at risk. A decision was made to intubate prophylactically. Which of the following would be contraindicated?
a. Oral intubation utilizing a glide-a-scope
b. Rapid sequence intubation
c. A nasogastric tube for decompression post-intubation
d. A temporary tracheostomy
c. A nasogastric tube for decompression post-intubation
C is correct because: don’t want to stick anything in the nose d/t fractures
A is incorrect because: this is becoming routine practice for intubation
B is incorrect because: this is needed for all intubations
D is incorrect because: while not first line, this is technically not contraindicated
30
As the patient is being prepared for discharge, she confides to you that the assailant was her domestic partner. They initially engaged in a verbal altercation, which ended in this physical abuse. She states this is the first time she has been abused during their relationship. What is your priority intervention?
a. Immediately call the local law-enforcement authorities – patient must give consent to do this or call them herself
b. Obtain a psychiatric/behavioral medicine consult
c. Discuss all options with the patient, including returning home with her domestic partner
d. Encourage the patient to leave her domestic partner and seek refuge in a local women’s shelter – have to give her all of the options and let her make the decision
c. Discuss all options with the patient, including returning home with her domestic partner
31
A 17-year-old male presents to the ER with what appears to be conjunctivitis. During an ophthalmic exam, which of the following would you document as an abnormal finding?
a. Arteries are brighter and wider than veins
b. A physiologic cup 40% the size of the optic disc
c. A yellow-orange optic disc
d. Absence of vessels in the macula
a. Arteries are brighter and wider than veins
A is correct because: veins are brighter and wider
B is incorrect because: the cup can be up to 50% the size of the optic disc
32
A 36-year-old female patient was admitted to the ICU secondary to drug overdose. During your evaluation today, the patient complains of ear pain. On otoscopic exam, you note a bulging tympanic membrane. She has a temperature of 102F (38.9C). What would be the most appropriate intervention?
a. Order empiric oral antibiotics
b. Order a decongestant and antihistamine
c. Obtain an aspirate culture of middle ear fluid
d. Order topical otic antibiotics
a. Order empiric oral antibiotics
A is correct because: otitis media is a systemic problem, classic picture of otitis media
D is incorrect because: would not treat acute otitis media, would treat otitis externa
33
A 48-year-old male was admitted for narrow angle glaucoma. Pending an ophthalmology evaluation, you order acetazolamide (Diamox) immediate-release formulation. The patient is also on HCTZ for HTN management. Which of the following laboratory abnormalities would be most important to monitor for?
a. Hypercalcemia
b. Hypokalemia
c. Hypernatremia
d. Hypoglycemia
b. Hypokalemia
B is correct because: both Diamox and HCTZ are non-potassium-sparing diuretics
C is incorrect because: would expect hyponatremia with Diamox
34
You are examining the corneal reflexes on a 25-year-old female who wears contact lenses. You appreciate the absence of a corneal reflex. What is your next step?
a. Refer to neurology
b. Document a normal finding
c. Document a normal variant
d. Refer to ophthalmology
c. Document a normal variant
C is correct because: in people that wear contacts, their corneal reflex goes away because they are always having to touch their eye to put the contacts in
B is incorrect because: this is never a normal finding but rather a normal variant
A and D are incorrect because: only refer/consult if the generalist provider cannot offer anything for the patient
35
Upon examining the eyes of an elderly patient, you notice a grey ring around the iris. What is the most likely diagnosis?
a. Corneal arcus
b. Cataracts
c. Glaucoma
d. Diabetic retinopathy
a. Corneal arcus
A is correct because: this is a normal variant in the elderly population
36
A 39-year-old male patient presents with significant periorbital pain, erythema, edema, and drainage from the left eye that began about 24 hours ago and has worsened over time. His temperature is 101.6F (38.7C). His medical history is significant for HIV with stable CD4+ count of 350 cells/microliter. His viral load is undetectable. He just completed a 10-day course of antibiotics (amoxicillin-clavulanate [Augmentin] 875 mg BID) for sinusitis. He states his symptoms were resolving, but yesterday his eye began to hurt and today he presents with symptoms as described above. What is the most appropriate intervention?
a. Admit the patient for IV antibiotics
b. Culture the drainage and assess for risk of gonococcal exposure
c. Obtain a CTA of the head to confirm the diagnosis
d. Change the patient’s prescription to an oral fluoroquinolone and discharge to home
a. Admit the patient for IV antibiotics
A is correct because: this is a picture of orbital cellulitis (patient had sinusitis, got a 10-day course of antibiotics, but symptoms returned)
C is incorrect because: would do a CT of the orbits
37
A 20-year-old female patient presents to the ER with a fever of 101.7F (38.7C), dysphagia, and a severe sore throat. The patient states she was recently treated for tonsillitis and noticed she had a sore throat again 4 days ago. She is scheduled for a tonsillectomy next week. What is the most likely diagnosis?
a. Mononucleosis
b. Peritonsillar abscess
c. Oral candidiasis
d. Gonococcal infection
b. Peritonsillar abscess
B is correct because: this is a classic picture of an adult treated for tonsillitis with return of the above symptoms
The other answers don't even make sense
38
Diabetic retinopathy symptoms/exam findings
* Early in disease process – asymptomatic
* Advanced – floaters, blurry vision, progressive visual acuity loss
* Microaneurysms – earliest sign (appear as small red dots)
* Flame-shaped hemorrhages, cotton-wool spots
* Intra-retinal microvascular abnormalities
39
Diabetic retinopathy management
* Controlling diabetes = #1
| * Refer to ophthalmologist or retinal specialist
40
Bell’s Palsy symptoms/exam findings
* Acute onset of unilateral upper/lower facial paralysis with no other neuro symptoms (may or may not have any other symptoms)
* Ear and/or pain
* Decreased hearing
* Weakness of facial muscles
* Poor eyelid closure
* Blurry vision
41
Bell’s Palsy management
* 4 day window to treat
* Corticosteroids – 60-80 mg x 5-7 days (Grade 1-3)
* Antivirals – valcyclovir 1g TID x7 days in addition to above corticosteroids (Grade 4-6)
* Lubricating eye drops + eye protective measures
42
Trigeminal Neuralgia symptom/exam findings
* Brief/paroxysmal episodes of stabbing unilateral face pain
* Usually one side of the mouth and shoots towards ear or eye
* Exacerbated by touch, movement, eating
* Normal neuro exam
* Diagnosis of exclusion
43
Trigeminal neuralgia management
* 1st line – antiepileptic (carbamazepine), taper up dose
* 2nd line – baclofen or lamotrigine
* Surgery for patients refractory to medical management
