CR - HEENT Flashcards
What are the key distinguishing clinical features that help differentiate croup from epiglottitis?
Croup - viral prodrome, gradual, cough with “seal bark” like quality, low grade fever, may see retractions
Epiglottitis - abrupt, uncommon to have cough, higher fever, tripod positioning
What is the appropriate initial study in a patient with headache, lethargy, nuchal rigidity, and papilledema?
Computed tomography (CT) of the head should be done initially to exclude the presence of mass lesions prior to lumbar puncture.
The important consideration here is subarachnoid hemorrhage, secondary to a ruptured aneurysm. If meningitis is a possibility, administration of antibiotics should not be delayed.
A “teardrop” shaped pupil in a patient with a history of trauma to the eye suggests what injuries?
Open globe
Clinical presentation: a patient presents with drooling and exquisite neck pain following a recent dental procedure. Brawny edema and protrusion of the tongue are appreciated. What is the diagnosis and next steps in management?
Ludwig’s Angina (cellulitis of the oral floor)
Management includes emergent surgical consultation, broad spectrum antibiotics, and early airway management
Clinical presentation: an adult male was struck in the eye by a fist 3 days ago. Over the past 24 hours, he has developed redness, pain and photophobia
- how would you confirm the diagnosis
- how is this treated?
The diagnosis is traumatic iritis. This is confirmed by a slit lamp examination which demonstrates cell and flare in the anterior chamber.
Treatment consists of analgesics, long-acting topical mydriatic-cycloplegic drops (dilate the constricted pupil, relax ciliary spasm) and topical corticosteroids (reduce inflammation)
Of all patients with epistaxis, the ones who must be admitted are those treated with ____
Posterior packing
The feared complications are:
Dislodgement and airway obstruction
Hypoxia and hypercarbia
Cardiopulmonary complications
Toxic shock syndrome
List the complications of a hyphemia
Rebleeding, which occurs 2-5 days after the initial clot loosens, is a major complication
Blood staining of the corneal epithelium
Secondary glaucoma
Anterior and posterior synechiae
Optic atrophy from increased IOP associated with hyphemia
What is the most common direct source of anterior nosebleeds?
What is the most common direct source of posterior nosebleeds?
Anterior nosebleed - kiesselbach plexus
Posterior nosebleed - posterior branches of the sphenopalatine artery
A patient presents within 3 days of a tooth extraction complaining of severe pain and of foul breath odor.
What is the diagnosis and treatment?
Acute alveolar osteitis (dry socket)
Anesthetic nerve block, irrigation, packing with iodoform gauze soaked in eugenol or camphorated phenol, and follow up with dentistry within 24 hours
What is the suspected diagnosis in patients who experience painless vision loss, a curtain-like shadow falling over their field of vision, “spider webs” or “flashing lights” in front of their eyes, especially at night and in their peripheral visual field?
Retinal detachment
Slit lamp exam of a painful eye reveals a fluorescein-positive area with branching or dendrite pattern.
What is the diagnosis and treatment of this disease?
Herpes Simplex Keratitis
Treatment:
1. topical and oral antiviral agents
2. topical cycloplegic drops
3. emergent ophthalmologic consultation
A fracture through the petrous portion of the temporal bone is known as a ____.
What are the most common clinical signs?
Basilar skull fracture
Clinical signs:
Raccoon eyes (periorbital ecchymosis with tarsal plate spared), battle sign (postauricular ecchymosis), hemotympanum, or CSF leak from nose or ear (halo sign or double ring pattern is seen when blood and CSF separate on paper or linen)
What are the most common causes of parotitis?
Viral: paramyxovirus (mumps), influenza, coxsackie A virus, epstein barr virus (EBV), HIV
Bacterial: staphylococcus aureus, borrelia burgdorferi (lyme’s disease)
Autoimmune: sjogren’s disease, rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis
What are the most common presenting symptoms of a brain abscess?
- Headache (50-75% of cases)
- fever (<50%)
- Neurologic deficit (20-57%)
- Triad (<20%)
Clinical presentation: a 55 year old woman has been experiencing a new onset headache with vision changes and jaw claudication.
Which abnormal laboratory finding is associated with the diagnosis? What are common ocular complications?
Diagnosis: temporal / giant cell arteritis
Lab: markedly elevated sedimentation rate (usually over 50 mm/hr). Maximum normal sedimentation rate can be calculated as age/2 if male and (10+age)/2 if female
Complications: optic nerve ischemia, central retinal artery occlusion
What is the organism that causes malignant otitis?
How is malignant otitis diagnosed and treated?
Pseudomonas aeruginosa
Diagnosis: CT (most appropriate emergency department imaging)
Treatment: ENT consult, IV antibiotics (fluoroquinolones or antipseudomonal cephalosporin), admission
Clinical presentation: a high school wrestler presents with right ear pain, swelling, and cauliflower deformity that developed a few days after a match. What is the diagnosis and treatment?
Auricular hematoma
Management:
-small (<2cm) and acute (<48 hrs): needle aspiration
- large (>2cm) and subacute (>48hr but <7 days): I&D
- >7 days: ENT/plastic referral
- Apply pressure dressing to prevent reaccumulation
- Daily follow up (3-5 days) to evaluate for reaccumulation/infection or necrosis of ear cartilage as a complication of pressure dressing
What are the complications of ethmoid sinusitis?
- periorbital / orbital cellulitis
- brain abscess
- cavernous sinus thrombosis
What is a complication of sphenoid sinusitis?
Cavernous sinus thrombosis
Mastoiditis is usually a complication of which disorder?
Untreated or inadequately treated acute otitis media
What is the treatment of mastoiditis?
- Immediate ENT consultation
- broad spectrum IV antibiotics (typically 3rd or 4th generation cephalosporin PLUS vancomycin)
- admission
A patient complains of severe sore throat, muffled hot potato voice as well as difficulty swallowing and opening the mouth?
What is the suggested diagnosis?
Peritonsillar abscess
Tip: look for uvular deviation
A patient with a history of blunt trauma to the face has enophthalmos (recognizable as slight ptosis) on physical examination.
Which diagnosis should be considered?
Blowout fracture of the orbit
Tip: consider carotid injury with traumatic horner’s syndrome (myosis, ptosis, anhidrosis and enophthalmos)
What is the currently recommended emergency treatment for complete laryngeal obstruction due to trauma?
Tracheostomy
- cricothyrotomy is usually not feasible because the injury is frequently below the cricothyroid membrane
-blind nasotracheal intubation attempts may penetrate the mediastinum - percutaneous transtracheal insufflation is currently under investigation
What are the most common causes of non-viral conjunctivitis based on age?
Conjunctivitis
Bacterial causes include N. gonorrhoeae in the newborn as the most vision-threatening, but c. trachomatis is the most common in the newborn. In adults the most common bacteria is s. aureus followed by h. influenza, s. pneumoniae, m catarrhalis
Age / etiology:
Neonates <24 hrs / chemical
Neonates 24-48hr / neisseria gonorrhea
Neonates 5-15 days / chlamydia trachomatis
Neonates 6-14 days / herpes keratoconjunctivitis
What re the characteristic fluoroscein uptake patterns in keratitis due to exposure, acanthamoeba and herpes simplex?
Exposure keratitis - horizonatal band
Acanthamoeba keratitis - ring shape
Herpes simplex keratitis - branching dendritic pattern
A patient experiences sudden, painless, monocular vision loss
Diagnosis:
Cherry red spot in the center of the fovea with a pale retina on a fundoscopic exam is associated with ___?
“blood and thunder” appearance on a fundoscopic exam is associated with ___?
Central retinal artery occlusion
Central retinal venous occlusion
Facial anesthesia - match the nerve block with the location
Neonatal conjunctivitis (ophthalmia neonatorum) occurs in the first 3-15 days of life. Which organisms are likely to be responsible
If it occurs in the first 3-5 days -> n. gonorrhoeae and/or HSV should be suspected
If it occurs between 5-15 days -> chlamydia trachomatis*, HSV, H. influenzae, s. pneumoniae, s. aureus or staphylococcus should be suspected.
- concomitant pneumonia may be present
Clinical presentation: a 12 year old male presents with atraumatic eye redness and pain that is worsened with eye movements. Examination reveals mild chemosis, proptosis, and an afferent pupillary defect. What is the diagnosis and treatment?
Diagnosis: orbital cellulitis
Treatment: broad spectrum antibiotics and ophthalmology consult
*** must distinguish from periorbital cellulitis
Periorbital cellulitis will also have eyelid swelling and erythema, but eye pain is less common, chemosis is rare, and pain with EOMI, proptosis, ophthalmoplegia, and vision impairment will NEVER be present
Spontaneous hypohemias are associated with ____
Sickle cell disease
Diabetes and neoplasms should also be considered
An acute cranial nerve III palsy with pupillary dilation is a ____ ____ ____ ____ until proven otherwise.
Posterior communicating artery aneurysm
You are examining a patient who seems to have a Bell’s palsy. When you check EOMs, he is unable to abduct the ipsilateral eye. What is the diagnosis?
A stroke masquerading as Bell’s palsy
Which diagnoses should be considered in a patient with an isolated cranial nerve palsy (III, IV, or VI) associated with pupil sparing?
Diabetic / hypertensive cranial nerve plasy
Commonly caused by untreated or ineffectively treated frontal sinusitis, what diagnosis is associated with a doughy-feeling tender mass above the eye?
Pott’s Puffy Tumor
Management: surgical consultation - ENT/Neurosurgery, broad spectrum IV abx for 4-6 weeks (e.g. clindamycin, ceftriaxone, metronidazole, vancomycin)
Complications include meningitis, epidural abscess, subdural empyema, and brain abscess
What medications have produced sudden attacks of narrow-angle glaucoma?
- Topical cycloplegics
- Anticholinergic agents
- beta-agonsits (including inhaled agents)
- sulfa, MAO inhibitors, tricyclics
Describe the differences between central versus peripheral vertigo
The most common acute optic neuropathy in patients > 50 years old is ____
Nonarteritic anterior ischemic optic neuropathy
Which potentially life-threatening disease should be excluded in patients in their sixties who complain of dull, aching eye pain that extends to the temple?
Ocular ischemic syndrome
(light-induced amaurosis should alert the clinician to the possibility of significant carotid occlusion)
Clinical presentation: A 25 year old female experiences sudden onset monocular blurry vision that started several hours ago. Eye movements of the affected eye have been painful and she endorses worsening of her vision with hot showers. You not an afferent pupillary defect on exam.
What is the diagnosis and management?
Diagnosis: optic neuritis
Treatment: IV corticosteroids
-Common causes include multiple sclerosis (most common), B12 deficiency, methanol poisoning, lupus, neurosarcoidosis, lyme disease, herpes, syphilis
- most cases are retrobulbar and will NOT have optic disc findings on fundoscopy
- Uhthoff’s phenomenon - transient worsening of vision with heat or exercise
A contact lens wearing patient with a corneal ulcer presents with an adherent mucopurulent exudate and a “ground glass” appearance of the cornea. What is the most likely infecting organism?
Pseudomonas aeruginosa
What are some key radiographic findings which can be used to differentiate epiglottitis and croup?
Steeple sign
Subglottic tracheal lumen narrowing found in croup alters radiographic appearance of tracheal air column which resembles a church steeple or inverted V on AP radiograph.
Thumb sign
Enlarged epiglottis (thumb sign), loss of vallecular air space, thickened aryepiglottic folds, distended hypopharynx, and loss of cervical lordosis are present in epiglottis
Clinical presentation: a patient is experiencing unilateral, painful swelling, erythema, and warmth to the region inferomedial to the eye. There is tenderness to the lacrimal sac and some purulent drainage.
What is the diagnosis and treatment?
Diagnosis: dacrocystitis
Treatment:
Mild infection - clindamycin
Severe infection - vancomycin, 3rd generation cephalosporin
What is the treatment for drug induced angioedema vs hereditary/acquired angioedema?
Management:
-supportive measures, early airway management
- drug induced - discontinue offending agent, administer anaphylaxis therapy (unlikely to be effective)
- hereditary / acquired - fresh frozen plasma (replace C1 esterase)
Patient presents after blunt orbital trauma with unilateral eye pain and decreased vision. Exam shows an intact globe, peri-orbital ecchymosis, proptosis, and an afferent pupillary defect. What is the diagnosis and the emergent treatment?
The diagnosis is retrobulbar hemorrhage (RBH) resulting in ocular compartment syndrome.
Emergent lateral canthotomy and cantholysis should be performed for ocular compartment syndrome with acute loss of visual acuity, relative afferent pupillary defect, increased IOP (>35), and proptosis
The management of an open globe injury should include?
Eye shield
Address tetanus status
Empiric systemic antibiotics for post-traumatic endophthalmitis
Consideration for CT scan
Immediate consultation with ophthalmology
Match the midface fracture with the proper description (LeFort Type I, II, or III)
__ pyramidal fracture involving nasofrontal suture
__ extensive transverse fracture that may result in craniofacial dislocation
__ horizontal fracture involving the alveolar ridge
Type II - pyramidal
Type III - craniofacial dislocation
Type I - horizontal
A 9 year old girl presents with peripheral facial nerve palsy (does not wrinkle forehead) after falling off a scooter. What is the most likely cause?
Temporal bone fracture
A 3 year old girl presents to the ED with right otitis media. What sign/symptom should prompt you to obtain imaging?
A. hearing loss
B. ear drainage
C. VI nerve plasy
D. seizure
VI nerve palsy
AKA gradenigo syndrome: acute otitis media with mastoiditis involving the petrous portion of the temporal bone causing VI nerve palsy
Clinical presentation: a patient was cutting metal earlier and believes something went into his eye. When examining his eye, you not fluorescein uptake that washes off when blinking with a pattern of smearing. What is the name of this sign and its significance?
Seidel sign
Foreign body penetration into the anterior chamber with aqueous humor leak
Name at least three ototoxic drugs that cause hearing loss
Common ototoxic medications:
- aminoglycosides
- erythromycin
- vancomycin
- antimalarials
- salicylates
- loop diuretics (furosemid)
- chemotherapeutic agents (platins)
Name at least 3 systemic disease with an oral manifestion
Common systemic disease with oral manifestations:
- infectious (HIV/AIDS, HSV, coxsackie, n. gonorrhoeae, syphilis, measles)
- autoimmune (SLE, reiter’s syndrome, sjogrens, behcet’s disease)
- toxicology (heavy metals, lead, silver)
- granulomatous disease (Tb, wegener’s)
- blood dyscrasia (acute leukemia, thrombotic thrombocytopenic purpura)
Clinical presentation: a patient presents with a painful unilateral maculopapular facial rash with vesicles, pustules, and crusting ulceration that does not cross the midline. There is upper eyelid involvement with edema and ptosis. What is the diagnosis and next steps in management?
Herpes zoster ophthalmicus
- involvmenet of ophthalmic branch (V1) of trigeminal nerve
management:
- cool compresses / lubrication drops
- topical antibiotics to prevent secondary infection
- antiviral therapy (acyclovir, famciclovir, valacyclovir)
- ophthalmology consultation regarding addition of steroids
Clinical presentation: a 60 year old male was in a movie theater when he began experiencing sudden onset severe unilateral eye pain with associated blurred vision and is endorsing halos around light sources. What is the diagnosis and next steps in management
Acute angle closure glaucoma
Common findings - IOP > 20 mmHg, mid-dilated nonreactive steamy pupil, perilimbal flush
Management:
- emergent ophthalmology consultation
- elevated HOB, place patient in well lit room
- topical beta-blocker, alpha-agonist, and PO acetazolamide
- measure IOP every hour after medications
- admission for definitive therapy with iridotomy
