EENT Flashcards
If a rupture of the globe is suspected, should you palpate?
No
Penetrating trauma treatment (3)
- The object should not be removed. Do no apply pressure. Shield the eye but avoid manipulation
- The patient should be transported to the emergency room and consult with ophthalmologist
- Pain can be alleviated with systemic analgesia or sedatives. Avoid eye drops. Parenteral antibiotics are recommended prophylactically
A rust ring on the cornea indicates what?
Metallic foreign bodies. These may be removed with a rotating burr or the patient may be referred to an ophthalmologist
Chemical eye burns treatment (3)
- The eye should be irrigated with water or normal saline for at least 30 minutes. Use sterile solution if available. A chemical burn can continue to cause damage even after flushing
- An eye shield should be placed on the eye
- Transport the patient to the emergency room and refer to an ophthalmologist
Blow-out fracture clinical features (4)
- Patients present with swelling and misalignment. Movement of the globe is restricted, specifically an inability to look up due to entrapment of the infraorbital nerve and the musculature
- Double vision is common
- Subcutaneous emphysema and exophthalmos are commonly present
- CT scan will delineate extent of the damage
Blow-out fracture treatment (3)
- Prompt referral to ophthalmologist
- Patients should be kept calm and avoid anything that can increase pressure (ex: sneezing)
- Nasal decongestants, ice packs or cold compresses, and antibiotics are started during transport
Corneal abrasion treatment (4)
- Topical anesthetic will provide immediate relief; however, it should be used only to assist in confirming the diagnosis and should not be prescribed because it may retard healing
- Saline irrigation will loosen debris. Antibiotic ointment, such as gentamicin or sulfacetamide, should be applied. Acetaminophen is given for analgesia
- Patching for no longer than 24 hours is recommended only for large abrasions (>5 to 10 mm) to promote healing. Patching for longer than 24 hours may retard healing
- Daily f/u of all abrasions is essential. Failure to heal should prompt referral to an ophthalmologist
Corneal ulcer may result from what?
Inflammation or infection
Risk factors for corneal ulcers
Trauma, contact lens use, or poor lid apposition
Corneal ulcer treatment (3)
- All corneal ulcers should be referred to an ophthalmologist
- Lesion should be stained and cultured to identify the cause
- Avoid topical steroids because they will cause further tissue loss and increase risk of perforation
Retinal detachment underlying pathogenesis
Separation of the retina from the pigmented epithelial layer, causing the detached tissue to appear as flapping in the vitreous humor
A retinal detachment tear most commonly begins where?
At the superior temporal retinal area
Causes of a retinal detachment
The tear can happen spontaneously or be secondary to trauma; extreme myopia; or inflammatory changes in the vitreous, retina, or choroid
Retinal detachment clinical features (3)
- The patient may report acute onset of painless blurred or blackened vision that occurs over several minutes to hours and progresses to complete or partial monocular blindness.
- It is classically described as a curtain being drawn over the eye from top to bottom
- The patient may sense floaters or flashing lights at the initiation of symptoms. Intraocular pressure is normal or reduced
What does the eye exam reveal in retinal detachment?
There will be a relative afferent pupillary defect. Fundoscopic examination may reveal the ridges (rug) of the displaced retina flapping in the vitreous humor
Retinal detachment treatment (2)
- An emergency consult with an ophthalmogist regarding possible laser surgery or cryosurgery is needed
- Patients with retinal detachment should remain supine, with the head turned to the side of the retinal detachment
Prognosis of retinal detachment
It is good: 80% will recover without recurrence, 15% will require treatment, and 5% will never reattach
Macular degeneration causes
It may be age related or secondary to the toxic effects of drugs, such as chloroquine or phenothiazine
What is the leading cause of irreversible central visual loss?
Macular degeneration
What is found in the Bruch membrane with macular degeneration and what does it lead to?
Drusen deposits are found and it leads to degenerative changes, loss of nutritional supply, atrophy, and later in the disease, neurovascular degeneration, which causes hemorrhage and fibrosis
Macular degeneration chief clinical feature
Gradual loss of central vision
What is metamorphopsia?
Phenomenon of wavy or distorted vision and can be measured with an Amsler grid
Macular degeneration treatment
There is no effective treatment. If detected early, laser therapy or intravitreal injections of monoclonal antibody drugs may slow the progression of macular degeneration
What may reduce the progression of macular degeneration
Vitamins, antioxidants, zinc and copper, and omega-3 fatty acids
Central retinal artery occlusion general characteristics (3)
- This disorder is considered to be an ophthalmic emergency; prognosis is poor, even with immediate treatment
- Common causes are emboli, thrombotic phenomenon, and vasculitides
- It must be differentiated from giant cell arteritis
Central retinal artery occlusion clinical features (2)
- It is characterized by sudden, painless, and marked unilateral loss of vision
- Fundoscopy reveals pallor of the retina, arteriolar narrowing, separation of arterial flow (box-carding), retinal edema, and perifoveal atrophy (cherry red spot). Ganglionic death leads to optic atrophy and a pale retina (blindness)
Central retinal artery occlusion treatment (2)
- Emergency referral to an ophthalmologist is necessary. Recumbent position and gentle ocular massage may help reduce the extent of damage. Vessel dilation and paracentesis are attempted to save the eye
- Workup and management of atherosclerotic disease or arrhythmias is warranted to reduce the risk of recurrence
Central retinal vein occlusion usually occurs secondary to what?
A thrombotic event. Risks include diabetes, hyperlipidemia, glaucoma, and hyperviscosity states (e.g., polycythemia, leukemia)
How do patients with central retinal vein occlusion usually present?
With sudden, unilateral, painless blurred vision or complete visual loss
Central retinal vein occlusion examination
It usually reveals an afferent pupillary defect, optic disc swelling, and a “blood and thunder” retina (dilated veins, hemorrhages, edema, and exudates)
Central retinal vein occlusion treatment (2)
- Vision typically is resolved with time, at least partially. A workup for further thrombosis is warranted
- Neovascularization can be treated with intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors
Nonproliferative diabetic retinopathy
Venous dilation, microaneurysms, retinal hemorrhages, retinal edema, hard exudates
Proliferative diabetic retinopathy
Neovascularization, vitreous hemorrhage
Cataracts may develop secondary to what?
It may develop secondary to the natural aging process (senile cataract, most common type) or due to trauma, congenital causes, systemic disease (diabetes), or medication use (e.g., corticosteroids, statins)
Cataract examination findings
On examination, there is a translucent, yellow discoloration in the lens. On fundoscopy, the cataract appears dark against a red background. Once mature, the retina is no longer visible
Glaucoma definition
It is defined as an increased intraocular pressure with optic nerve damage. Any impediment to the flow of aqueous humor through the trabecular meshwork and canal of Schlemm will increase pressure in the anterior chamber
Which type of glaucoma is most common
Open-angle (it affects people older than 40 years and is more common in African Americans and in patients with a family history of glaucoma or diabetes)
Angle-closure glaucoma is an ophthalmic emergency resulting from complete closure of the angle. What are the signs/symptoms?
- Painful eye and loss of vision are important clinical features
- Physical exam reveals circumlimbal injection, steamy cornea, fixed mid-dilated pupil, decreased visual acuity, and tearing
- The anterior chamber is narrow; intraocular pressure is acutely elevated
- Nausea, vomiting, and diaphoresis are common
Open-angle glaucoma is a chronic, asymptomatic, and potentially blinding disease that affects 2% of the population. What are the signs/symptoms?
- It manifests as increased intraocular pressure (IOP), defects in the peripheral visual field, and increased cup-to-disc ratios
- Patients are typically asymptomatic until late in the disease. Loss of peripheral vision is the main symptom
- Elevated IOP without optic disc damage is known as ocular hypertension. Close monitoring is warranted
- Optic nerve damage without increased IOP is also seen. Subsequent monitoring typically reveals increasing IOP
Angle-closure glaucoma treatment
- These patients must be referred immediately to an ophthalmologist. Start IV carbonic anhydrase inhibitor (i.e., acetazolamide), topical beta blocker, and osmotic diuresis (i.e., mannitol)
- Mydriatics should not be administered to these patients
- Optimal treatment is via laser or surgical iridotomy
Open-angle glaucoma treatment
- Patients should be referred to an ophthalmologist for close monitoring and chronic treatment
- Treatment consists of topical and/or systemic medications to decrease the IOP by decreasing aqueous production (beta blockers, carbonic anhydrase inhibitors) and/or increasing outflow (prostaglandin like-medications, cholinergic agents, epinephrine components). Alpha-agonists (brimonidine) provide both mechanisms
Orbital cellulitis is primarily associated with what?
Sinusitis
Causative agents of orbital cellulitis
Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and gram-negative bacteria
Symptoms of orbital cellulitis
Ptosis, eyelid edema, exophthalmos, purulent discharge, and conjunctivitis
Examination of orbital cellulitis
It will reveal fever, restricted ROM of the eye muscles, edema and erythema of the lids and surrounding skin, and a sluggish pupillary response
Orbital cellulitis diagnostic studies
- CBC, blood cultures, and cultures of any drainage
2. CT is recommended to determine the extent of the disease. CT will show broad infiltration of the orbital soft tissue
Orbital cellulitis treatment
- Orbital cellulitis constitutes a medical emergency requiring hospitalization, IV antibiotics, and surgical drainage if recalcitrant or recurrent. Inadequate treatment can lead to meningeal or cerebral infection
- Antibiotics should be broad spectrum until the causative agent is identified. Continue IV administration until fever subsides, then complete 2-3 weeks of oral antibiotics
- Recommended regimens include nafcillin and metronidazole or clindamycin, second-or third-generation cephalosporin, and fluoroquinolone. If MRSA is suspected, treat with vancomycin
What is dacryostenosis?
It is a common condition in the newborn after the first month of life and occurs when the duct does not open
Dacryostenosis treatment
It usually resolves by 9 months of age. Treatment includes warm compresses and massage; if no resolution, surgical probe is indicated
What is dacryocystitis?
It is an inflammation of the lacrimal gland caused by obstruction. Common pathogens include S. aureus, beta-hemolytic streptococci, S. epidermis, and Candida sp.
Dacryocystitis treatment
Treatment is warm compresses and antibiotics. If an abscess forms, incision and drainage may be required. Surgical interventions may help if the condition is recalcitrant
What is blepharitis?
It is a chronic inflammation of the lid margins
Blepharitis causes
Causes include seborrhea, staphylococcal or streptococcal infection, and dysfunction of the meibomian glands
Blepharitis clinical features (4)
- Rims are red, and eyelashes adhere
- Dandruff-like deposits (scurf) and fibrous scales (collatettes) may be seen
- The conjunctiva is clear or slightly erythematous
- Thick, cloudy discharge will be visible if the meibomian glands are obstructed
Blepharitis treatment
- Lid scrubs using dilated baby shampoo on cotton-tipped swabs are helpful. Massage to express meibomian glands
- Topical antibiotics can be used if infection is suspected. Systemic antibiotics are reserved for recalcitrant cases
What is a hordeolum?
It is an acute development of a small, mildly painful nodule or pustule within a gland in the upper or lower eyelid
Internal hordeola are caused by what?
They are caused by the inflammation and infection of a meibomian gland, with pustular formation in that gland. They are situated deep from the palpebral origin
External hordeola are caused by what?
They are caused by the inflammation and infection of the glands of Moll or Zeis, with pustular formation in those glands. They are situated immediately adjacent to the edge of the palpebral margin
What is the typical causative agent of a stye?
S. aureus
Chiazzino general characteristics
- This is a relatively painless, indurated lesion deep from the palpebral margin
- It often is secondary to a chronic inflammation of an internal hordeolum of the meibomian gland
Entropion (lid and lashes are turned in) is secondary to what?
Scar tissue or a spasm of the orbicularis oculi muscles
Ectropion (edge of the eyelid everts) is secondary to what?
Advanced age, trauma, infection, or palsy of the facial nerve
Treatment of entropion and ectropion
Involves surgical repair if the condition causes trauma (trichiasis), excessive tearing, exposure keratitis, or cosmetic distress
Viral conjunctivitis is usually caused by what?
Adenovirus type 3, 8 or 19
Treatment of viral conjunctivitis
- Therapy includes eye lavage with normal saline twice a day for 7-14 days; vasoconstrictor-antihistamine drops also may have beneficial effects
- Warm to cool compresses reduce discomfort
- Ophthalmic sulfonamide drops may prevent secondary bacterial infection but are not routinely prescribed
Common pathogens of bacterial conjunctivitis
Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus aegyptius, and Moraxella sp.
Causes of papilledema
Numerous but includes malignant hypertension, hemorrhagic strokes, acute subdural hematoma, and pseudotumor cerebri
Lesions anterior to the optic chiasm will affect what?
One eye
Lesions at the optic chiasm will affect what?
Both eyes partially
Lesions posterior to the chiasm will yield what?
Corresponding defects in both visual fields
What is amblyopia?
Reduced visual acuity not correctable by refractive means
Amblyopia causes
Strabismus (most common); uremia; or toxins, such as alcohol, tobacco, lead, and other toxic substances
Blue or cyanotic sclera causes
May be normal or seen in infants with osteogenesis imperfecta
Most common causes of hearing impairment/loss
Cerumen impaction, eustachian tube dysfunction (secondary to URI), and increasing age (presbycusis)
With conductive loss, what does the Weber test and Rinne test show?
The Weber test shows lateralization to the affected ear. The Rinne test may also show greater bone conduction than air conduction on the affected side
With sensorineural hearing loss, what does the Weber test and Rinne test show?
The Weber test results in lateralization to the better hearing or unaffected side. The Rinne test will show air conduction is better than bone conduction
What is the most common etiology of sensorineural hearing loss?
Presbycusis
Meniere’s disease general characteristics
- Also known as endolymphatic hydrous, Meniere’s disease has an unknown etiology
- Symptoms appear to be related to distention of the inner ear’s endolymphatic compartment
Meniere’s disease clinical features (2)
- The typical syndrome involves recurrent vertigo (episodes lasting minutes to hours), with lower range hearing loss, tinnitus, and one-sided aural pressure
- With caloric testing, nystagmus is lost on the impaired side
Meniere’s disease treatment
- Initial treatment consist of a low-sodium diet and diuretics (i.e., acetazolamide)
- Unresponsive cases may be treated with more invasive procedures (i.e., intratympanic corticosteroid therapy, surgery)
Acoustic neuroma (vestibular schwannoma) definition
It is an intracranial benign tumor affecting the eighth cranial nerve
Acoustic neuroma (vestibular schwannoma) clinical features
It is usually unilateral and may present with progressive one-sided hearing loss with impaired speech discrimination. The hearing loss may also present more acutely. Other symptoms include vertigo, which is usually continuous rather than episodic
Acoustic neuroma (vestibular schwannoma) diagnosis
Usually by MRI
Acoustic neuroma (vestibular schwannoma) treatment
It takes into account patient age, health status, and tumor size and can involve surgery or focused radiation
Some common examples of ototoxic agents
Aminoglycosides, loop diuretics, and anticancer drugs (i.e., cisplatin)
Congenital causes of infancy and childhood hearing loss
These include asphyxia, erythroblastosis, and maternal rubella
Acquired causes of infancy and childhood hearing loss
Measles, mumps, pertussis, meningitis, influenza, and labyrinthitis
Most common offending agents for acute otitis media
Streptococcus pneumoniae, H. influenzae, Moraxella catarrhalis, and Streptococcus pyogenes
Otitis externa treatment
- Treatment involves antibiotic drops (amino glycoside or fluoroquinolone +/- corticosteroids) and avoiding further moisture or ear injury
- In diabetic or immunocompromised patients, malignant otitis externa may develop, which is a necrotizing infection extending to the blood vessels, bone, and cartilage; this requires hospitalization and parenteral antibiotics
Peripheral causes of vertigo
This includes labyrinthitis, benign positional vertigo, Meniere syndrome, vestibular neuritis, and head injury
Central causes of vertigo
Brainstem vascular disease, arteriovenous malformations, tumors, multiple sclerosis, and vertebrobasilar migraine
Peripheral vertigo clinical features
It is associated with sudden onset, n/v, tinnitus, hearing loss, and horizontal nystagmus
Central vertigo clinical features
It is associated with a more gradual onset and vertical nystagmus. Unlike peripheral vertigo, it does not present with auditory symptoms. Central vertigo is commonly associated with motor, sensory or cerebellar deficits
Possible complications of sinusitis
this includes orbital cellulitis, osteomyelitis, or cavernous sinus thrombosis
Antibiotics for sinusitis
Amoxicillin is a first-line drug. Course is usually 7-10 days (or longer to avoid relapse). Macrolide’s, TMP-SMX, or doxycycline can be used if penicillin-allergic. Amoxicillin-clavulanate can be used (10-day course) if there is no improvement after 3 days of first-line agents or after recent antibiotic use (within last 4-6 weeks). Quinolones, such as levofloxacin or moxifloxacin, can be used with treatment failures or recent antibiotic use
What are some group A beta-hemolytic streptococci (GABHS) suggestive manifestations
Fever, tender anterior cervical adenopathy, lack of cough, and pharyngotonsillar exudate
Pharyngitis treatment
IM penicillin can be used if patient compliance is in doubt. Otherwise, an oral penicillin or cefuroxime can be used. Erythromycin or another macrolide can be substituted in cases of penicillin allergy
Inadequate treatment of pharyngitis can lead to complications such as what?
Scarlet fever, glomerulonephritis, and abscess formation
Antibiotic choices in peritonsillar abscess/cellulitis (quinsy)
Parenteral amoxicillin, amoxicillin-sulbactam, and clindamycin. In less severe cases, oral antibiotics can be used for 7-10 days (i.e., amoxicillin, amoxicillin-clavulanate, clindamycin)
Antibiotic choices for laryngitis
Erythromycin, cefuroxime, or amoxicillin-clavulanate
Treatment of aphthous ulcers (canker sores, ulcerative stomatitis)
- Treatment is nonspecific, but topical therapies, such as corticosteroids, can provide some symptomatic relief
- A 1-week oral prednisone taper can also be helpful
- Cimetidine can be used as maintenance therapy in recurrent cases
With a history of nasal polyps and asthma, what medication(s) is contraindicated because of the possibility of causing severe bronchospasm, also known as triad asthma (Samter triad)?
Aspirin
