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EENT Flashcards

1
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Bacterial Conjunctivitis

  • Staph aureus (adults)
  • Strep pneumoniae, Haemophilus influenzae, Moraxella catarrhalis (children)
  • S/s: rapid onset, drainage causing sticky/matting of eyes
  • Tx
    • Azithromycin (1gt bid 2d, then 1gt daily 5d)
    • Bacitracin (1-2gtt q3-4h 7-10d)
    • Trimethoprim (1-2gtt q3-4h 7-10d)
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2
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Hyperacute Bacterial Conjunctivitis

  • Neisseria gonorrhoeae
  • S/s: severe discharge, lid swelling, chomosis (swelling of conjunctiva), VISION LOSS
  • Tx: hospitalization
    • Trimethoprim (1-2gtt q3-4h 7-10d)
    • Bacitracin (1-2gtt q3-4h 7-10d)
    • Azithromycin (1gt bid 2d, then 1gt daily 5d)
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3
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Viral Conjuntivitis

  • adenoviruses (common cold virus)
  • S/s: “scratchy/gritty” eye, may have hx upper respiratory prior, drainage thicker in morning/clearer as day progresses
  • Tx:
    • allow 2-3 weeks to resolve on its own
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4
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Allergic Conjunctivis

  • IgE mediated mast cell degranulation with release of histamine & others
  • S/s: itching, no significant discharge
  • Tx:
    • Olopatadine hydrochloride 0.1%/0.2% (Patanol)
    • Azelastine hydrochloride 0.05% (Optivar)
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5
Q

Nonallergic Conjuntivis

A
  • irritant or chemical exposure
  • Tx:
    • removal of foreign body
    • irrigation after chemical splash
    • removal of irritant and time
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6
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Dx of Conjunctivitis

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  • no dx testing unless:
    • The presence of ocular pain, headache, foreign body sensation, fixed pupil and/or vision changes requires further investigation
    • always ask about contact lens wear
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7
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Uveitis (irititis)

  • inflammation of uvea structures: iris, ciliary body (anterior), choroid (posterior)
  • causes: infections, SID, drug rx, ocular disease
  • S/s:
    • anterior: PAIN, redness at limbus, photophobia
    • posterior: less pain, vision change/floaters
  • Tx:
    • refer to opthalmologist - slit lamp exam reveals leukocytes
    • ocular steroids (MD Rx only)
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8
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Bacterial Keratitis

Infection of the cornea: anterior surface of eye

  • Staph aureus, Pseudomonas, Strep pneumoniae, Klebsiella pneumoniae
  • contact lens wear, corticosteroid eye drops
  • Dx:
    • corneal round, white opactity visible w/ penlight
    • also acute red eye, discharge, foreign body sensation, photophobia
  • Tx:
    • emergency requiring same-day referal to opthalmology
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9
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Viral Keratitis

Infection of the cornea: anterior surface of eye

  • Herpes simplex 1 & 2 (latent HSV1 recurrence primarily)
  • laser UV tx; eye rx: corticosteroids, epiniphrine, b-blockers, prostaglandins; immunosuppressed
  • Dx:
    • dendritic lesions seen w/ fluorescein stain
    • blurred vision, injection near limbus, decr. corneal sensation, variable pain, watery drainage, photophobia
  • Tx:
    • refer to opthalmologist- will Rx topical antivirals NO topical steroids
    • Trifluorothymidine drops, ganciclovir gel, oral acyclovir
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10
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Episclaritis

inflammation of fine vascular tissue covering anterior sclera

  • idiopathic (rarely systemic: dry eye, TB/syphilis, immune-mediated rxn)
  • Dx:
    • very vascular: bright red, NO PAIN, no vision change
    • if recurring: CBC, CMP, UA, ESR, CRP for underlying disease
  • Tx:
    • referral to optholmologist
    • self-limited, resolves in ~3wks, artificial tears & NSAIDs for pain
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11
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Scleritis

white avascular, fibrous outer coating of eye

  • associated with systemic disease 50% of time - inflammation/infection
  • Dx:
    • deep red/purplish color to sclera
    • pain w/ palpation, severe, constant “boring” pain, radiating to periorbital region, worse with eye movement, can impair sleep
  • Tx:
    • URGENT refer to opthalmology - NSAIDs and immunosuppressants
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12
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Blepharitis

inflammation of both eyelids

  • thought to be staph colonization
  • Dx:
    • crusty/flaking skin on lashes, red/itchy eyes, gritty/burning, incr. tear, eyelid swelling/erythema, blurred vision
  • Tx:
    • lid hygiene: warm compress, massage, q-tip wash
    • topical Azithromycin (erythromycin topical, bacitracin oinment also)
    • oral abx: azithromycin, doxycycline, tetracycline
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13
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Corneal Abrasion

  • foreign body impacting the eye - history important
  • Dx:
    • fluorscein stain uptake
  • Tx (all topical):
    • rythromycin ointment -or- sulfacetamide
    • contanct lens abrasion:
      • ofloxacin
      • ciprofloxacin
      • tobramycin drops
    • REFER IF:
      • corneal infiltrate, white spot, ulceration (top & middle pic)
      • hypopyon: pus in anterior chamber (bottom pic)
      • increasing pain
      • significant vision change (2 lines on Snellan chart)
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14
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Hordoleum (“stye”)

  • Staph aureus (most commonly) but can be sterile
  • Dx:
    • acute/rapid onset w/ erythema
    • arises from eyelash follicle
  • Tx:
    • warm compresses qid
    • Abx not helpful unless cellulitis present
    • usually resolves on its own in 7-10 days
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15
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Chalazion “lazy one”

  • may begin as hordoleum and result with Zeis or Meibomian gland obstruction
  • Dx:
    • rubbery and painless, lacks erythema
  • Tx:
    • hot compresses - but can take weeks
    • refer to opthalmololgist for I&D or glucocorticoid injection if no resolution
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16
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Dacryoadenitis (Dacryo = tears)

  • S. aureus, S. pneumoniae, Pseudomonas, N. gonnorhoeae, measles, mumps, flu infection of lacrimal gland
  • Dx:
    • S-shaped eyelid
    • fever, fatigue, red/swollen eyelid, erythema of bulbar conjunctiva, tender to palpation
  • Tx:
    • CT of orbits and sinuses to rule out involvement
    • Abx:
      • Cephalexin (beware MRSA)
      • Clindamycin 150-300mg q6h
      • IV vancomycin followed by TMP-SMX PO
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17
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Daryocystitis (daryo = tears)

  • S. aureus, S. pneumoniae, H. influenza infection of lacrimal duct
  • Dx:
    • rapid onset of erythema/swelling of lacrimal gland
    • infection can spread to orbital cellulitis, abscess, or enter conjunctiva
    • infants & old w/ obstruction or narrowing of duct
  • Tx:
    • refer to opthalmologist
    • Abx:
      • cephalexin (beware MRSA)
      • clindamycin 150-300mg qid
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18
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Orbital Cellulitis

  • mcc: S. aureus, streptococci in ethmoid sinuses then extends
    • orbital (inflammation of extraocular mm. and fatty tissue):
      • ocular pain/swelling, fever, PAIN w/ EYE MOVEMENT, ophthalmoplegia/diplopia
      • can lead to abscesses, vision loss, cavernous sinus thrombosis, death
      • Tx:
        • CT to distinguish from preseptal
        • opthalmology consult w/ hospitalization
        • vancomycin+ceptriaxone/ampicillin-sulbactam/pipercillin-tazobactam
    • preseptal cellulitis (outside orbit):
      • ocular pain and swelling (milder)
      • clindamycin or TMP-SMX
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19
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Pterygium (the triangle)

  • triangular wedge of fibrous conjuntival tissue forming medially and extending laterally, due to UV exposure causing RNA/DNA change
  • mainly cosmetic but can involve cornea, impair vision, restrict movement
  • Tx:
    • supportive: artificial tears
    • surgery (but frequently recur)
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20
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Pinguecula

  • white to yellow thickened area of limbus, looks “fatty” and adjoins the limbus
  • often bilateral and more common with age
  • Tx:
    • topica corticosteroids and opthalmic NSAIDs (both carry long-term risks)
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21
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Entropion

  • INWARD rotation of eyelids
  • can cause corneal abrasions and scarring, sensation of foreign body, tearing and irritation worsens with time
  • Tx:
    • referral to opthalmologist for surgery
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22
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Ectropion

  • OUTWARD turning eyelid
  • acquired and congenital causes
  • exposes conjuntival surface causing keratinization of epithelium, foreign body sensation, dryness, photophobia, tearing, conjunctivitis, vision can be affected
  • Tx:
    • referral to opthalmology
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23
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Hyphema

  • blood in anterior chamber most commonly from trauma or spontaneous: tumors/melanoma, neovascularization disease (ex. diabetes), clotting disorders, warfarin/aspirin, sickle cell, surgery - in children possible abuse
  • Dx:
    • significant pain, vision loss, NAV, photophobia
  • Tx:
    • opthalmologist referral
    • address any trauma, eye sheild, bed rest/elevate head, avoid light
    • ocular anesthetics: Proparacaine
    • oral/IV narcotics
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24
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Subconjunctival Hemorrhage

  • bleeding in small vessels in conjunctiva that can look like blood will “pour out of eye” from sneezing, coughing, straining, vomiting
  • usually benign - no pain, photophobia, vision loss
  • resolves over 1-2 weeks
  • caveats:
    • in presense of trauma evaluate rupture of globe - opthalmologist referral
    • if recurrent evaluate for bleeding or dyscasias (imbalance in blood)
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25
Cataracts * leading cause of blindness - progressive "myopic shift" from increasing opacity of lens * Dx: * darkened red reflex * opacities visible within red reflex * obscure fundus exam * Tx: * non-urgent referral to opthalmologist
26
Strabismus * misaligned eyes the majority of cases thought to be genetic but also palsy of cranial nerves controlling eyes, prematurity and low birth weight increase risk * if adult: think thyroid disease or myasthenia gravis * Eval: * history: birth & family hx, age of onset, freq., trauma, toxins, other med cond. * physical: complete incl neuro, PERRLA (pupils equal round reactive light accommodation), EOMI (extra occular movement intact), corneal light reflex, cover test * **Bruckner Test:** red reflection more intense in deviated eye * Tx: referral to pediatric opthalmologist
27
causes and treatments
Amblyopia (Lazy Eye) * any disorder where one eye functions better die to visual cortex development in early childhood - dominant eye "takes over" and other does not develop normally * crucial time period is age months to 7-8 * Causes: * strabismus- varying images causes one to be suppressed (training, surgery) * anisometric amblyopia (unequal refraction)- born with significant refraction differences between eyes (glasses) * deprivation amblyopia- obstruction of image, usally results in vision loss if not treated quickly (remove/correct problem) * this is a referral * eye terminology: * hypotropia * hypertropia * exotropia * esotropia
28
Central Retinal Artery Occlusion (CRAO) * "stroke of the arteries of the eye" most commonly caused by atherosclerosis * S/s: * _acute onset vision loss_ (painless) - can be preceeded by transient loss * Dx: * cherry red spot on macula ("Jupiter") * complete or relative pupillary afferent defect * \>50 get ESR and CRP to check for temporal arteritis * Tx: * SEND TO ER: opthalmic emergency
29
Central Retinal Vein Occlusion (CRVO) * 2nd most common vascular cause of blindness after diabetes * Types: * CRVO- entire retina affected by thrombus * branch RVO- distal retina involved * HemiRetinal VO- half of retina involved * Dx: * acute onset of painless vision loss * "blood and thunder" appearance (Venus/venous) * "cotton wool" spots * Tx: immediate referral to opthalmologist
30
Retial Detachment * separation of neurosensory retina from underlying retinal pigment epithelium and choroid ("folded appearance" of retina) - typically due to trauma, surgery, CMV retinitis, myopia, flouroquinolones * S/s: * photopsia (flashing light), floaters, "curtain falling" * Dx: * visual acuity test, confrontational visual field test, opthalmoscopy * Tx: * immediate referral to opthalmologist
31
Age Related Macular Degeneration (AMD) * degeneration of macula due to age, tobacco, genetics, CVD, hx cataract surgery * Dry: * slow/gradual vision loss * scotomas (blind spot) * difficulty reading * Wet: * loss of central vision over weeks/months (can start in one and progress * Metamorphopsia (distortion in visual field- Amsler grid) * Tx: opthalmology referral
32
Open Angle Glaucoma (90%) * _diminished_ drainage of aqueous humor through trabecular meshwork * risks: AA \>40, diabetes, myopia, fam hx * Dx: * cupping of optic disc head * asymptomatic peripheral vision loss * increased intraocular pressure (33-50% of pts.) * Tx: w/ opthalmologist (topical tx or surgery) * incr. outflow: prostaglandins, a-adrenergic/cholinergic agonists * decr. aq. prod.: a-adrenergic agonists, b-blockers, carbonic anydrase inhib.
33
headache decreased vision halos eye pain NAV cloudy cornea, conjuntival redness, shallow anterior chamber, poorly reactive pupil
Angle Closure Glaucoma * lens too far foward and abducts iris _stopping_ flow of aqeuous humor * S/s: * dramatic vision loss in hours-days * Tx: * EMERGENCY- send to ER or opthalmology immediately * b-blocker and other meds then laser iridotomy
34
Diabetic Retinopathy * prolonged/chronic hyperglycemia * Non-proliferative: * early in disease (end 10-20yrs) * microaneurysms, hemorrhages, cotton-wool spots (nerve infarcts), lipid deposits * Proliferative: * growth of new vessels (neoplasia) * Tx: * annual monitoring/exams * laser photocoagulation of vessels
35
Vitreous Hemorrhage (clear gel-like substance filling eye) * aging/trauma/DM causes liquification and shrinking then posterior vitreous detachment (PVD) and bleeding * Dx: * bleeding, vision loss, floaters, blurring, cobwebs * Tx: * emergent opthalmology referral if trauma/tear * surgery by retinal specialist
36
flame hemorrhages hard exudates ("yellow fat") AV nicking and narrowing cotton wool spots
Hypertensive Retinopathy * malignant HTN causing changes in retina, choroid and optic nerve - blindness or vision changes rare * Tx: * treat underlying HTN
37
Malignant Hypertension * optic disk swelling: BP \> 200/130, increased ICP * S/s: * headache, scotoma, diplopia, decreased vision, photopsias (flashes of light) * more damaging than chronic HTN * Tx: * rapid lowering of BP: 10-15% first hr and 25% by end of day
38
warm, swollen, red auricle
Perichondritis * Pseudomonas (mcc), S. aureus, S. pyogenes: piercings, cuts, burns, sports * Dx: * compare ears facing forward * Tx: * Flouroquinolones- * Levofloxacin 750mg qd x 7d * Ciprofloxacin 500mg bid x 7d * remove all ear jewelry * 48-72hr follow-up and ENT immediately if no improvement
39
Cerumen Impaction * apocrine and eccrine gland secretions mix with squamous epithelium to form ph4-5 protective cerumen * Dx: * visual observation, hearing loss, pain or onset of otalgia Tx (removal): * OTC Debrox (carbamide peroxide) * irrigation w/ hydrogen peroxide * DO NOT FLUSH if TM perforated or cannot confirm
40
rapid onset of pain tenderness w/ tragus palpation otorrhea white/yellow cerumen appearance edamatous canal
Otitis Externa ("swimmer's ear") * Principles of Tx: * pain management * remove debris * topical meds * avoid contributing factors (water, etc)
41
Acute Infective Otitis Media * typically swimmers * Tx: * debridement * topical therapy: * ciprofloxacin/hydrocortisone (Cipro HC) * ciprofloxacin/dexamethasone (Ciprodex) * hydrocortosone/acetic acid (bacterial or fungal) * ruptured TM: Ofloxacin otic drops * Otowick if canal swollen
42
Necrotizing Malignant Otitis Media * granulation tissue or exposed bone, purulent otorrhea \> 1mo, persistent otalgia * cranial n. involvement and facial palsy * Tx: * Hospital admission * CT scan for temporal bone involvement and culture * surgical debridment * IV Ciprofloxacin
43
Fungal Otitis Externa (Otomycosis) * aspergillus (mcc) often from abx overtreatment or trapped moisture * Dx: * thick white/gray discharge or fuzzy appearance * Tx: * Acetic acid otic (VoSol) EXCEPT if TM perforated - refer to ENT
44
Eczematous Otitis Media * includes: atopic dermatitis, psoriasis, lupus, eczema * dry, itchy, flaky skin * Tx: * topical steroid drops * Fluoinolone otic (DermOtic)
45
Herpes Zoster Oticus * "shingles of the ear" - burning pain followed by eruption of rash * Ramsay-Hunt Syndrome * Tx: * antivirals * Acyclovir * Famciclovir * Valcyclovir * oral steroid: prednisone
46
Normal Tympanic Membrane * cone of light indicates no fluid or infection behind membrane
48
* retracted tympanic membrane (measured w/ tympanogram) * short process of malleolus at 12 o'clock position appears shorter * S/s: * conductive hearing loss * sensation of fullness * gurgling, crackling, popping/snapping noises in ear * decreased TM mobility * allergic symptoms
Eustacian Tube Dysfunction (ETD) * Tx (treat the source): * oral decongestant- pseudoefedrine (Sudafed) 60mg PO q8hr * intranasal decongestant - oxymetabolism (Afrin) * antihistamines * Allegra 180mg/day * Loratadine 10mg/day * expectorant - Mucinex OTC * no improvement after 6 weeks consider myringotomy with tubes
49
Non-Otologic Causes of Otalgia (ear pain)
normal appearance of canal and TM * malignancy: * nasopharynx, pharynx, tonsil, tongue, larynx * tobacco/alcohol * infection * herpes zoster, tonsillitis * neurologic * trigeminal neuraligia (Tx: carbamazepine- anticonvulsant) * TMJ * pain/clicking with jaw movement, bruxism - grinding * refer to dentist, NSAIDs, mm relaxants, mouth splints
50
Serous Otitis Media * "honey" behind TM * Tx * watchful waiting (3mo) as often resolves spontaneously- eval hear/speech * autoinsufflation ("popping ears") * decongestants * pseudoepedrine (Sudafed) / phenylephrine (Sudafed PE) * antihistamines * myringotomy for persistent cases * Abx not recommended (but often used)
51
mild to severe/disabling otalgia (unilateral or bilateral) children may have fever, NAV, diarrhea hearing loss, irritability
Acute Otitis Media * bacterial or viral infection (may be associated with upper respiratory symtoms and fever) * bacteria (head big 3): H. influenza, M. catarrhalis, Group A strep * virus: RSV, corona virus, adenovirus, influenza, human metapneumovirus * if neurologic signs (headache, confusion, facial paralysis, vertigo) - **send to ER**
52
Acute Otitis Media Bullous Myringitis * appearance of hemorrhagic blebs on TM resulting from infection
54
Otitis Media Definitions
* Acute "suppurative" OM * inflammation of the middle ear and TM - viral or bacterial **infection** * Serous "non-suppurative" OM * residual effusion **post-acute infection** or related to ETD * acute: \<3wk, subacute: 3wk-3mo, chronic: \>3mo * Chronic OM * **infection** present in middle ear with tympanic membrane perforation * may have cholesteatoma
55
Mastoiditis * complication of acute otitis media days-weeks after onset * strep pneumoniae infection of mastoid air cells * Tx: * Vancomycin + ceftriaxone IV * culture if no improvement with Abx after 48hrs * mastoidectomy if tx fails * Cx: * perforation of TM or postauricular subperiosteal abscess * temporal lobe abscess or septic thrombosis of the lateral sinus
56
Chronic Otitis Media * can result from AOM or eustachian tube obstruction, mechanical trauma, blasts, PE tube, thermal/chemical burns * Dx: * P. aeruginosa, Proteus species, S. aureus infections * Drainage cultured if: choleseatoma or other complications suspected * febrile patient / vertigo / otalgia * CT or MRI to check for labyrinthitis, ossicular, temporal erosion and abscesses
57
Cholesteatoma * prolonged ETD and retraction of TM creating squamous lined sac filled with desquamated keratin leading to chronic infection * erodes bone and ossicular chain, affects facial nerve over time * Tx: * surgery
59
Tympanosclerosis * hard white plaque on the TM ("scarring" of the TM)- fibrosis due to frequent infections causing hemorrhage in the layers of the TM * asymptomatic but cat lead to conductive hearing loss * Tx: * none if asymptomatic * if hearing loss: explore tympanotomy or tympanoplasty * hearing aid
60
Tympanic Membrane Perforation * due to infection, trauma, PE tube placement * S/s: * sudden severe pain (if traumatic) then bleeding from ear * hearing loss is ossicular chain disrupted * _tinnitus_ * vertigo suggests inner ear injury * audible whistling during sneezing/nose blowing * purulent otorrhea- may begin after 24-48hrs if water enters * Tx: * NO air or irrigation of canal until perforation is ruled out * no tx if acute due to trauma- keep ear dry * topical abx if due to infection or contaminated water * surgery if perforation lasts \>2mo * spontaneous closure if right size, location, associated patho condition *
63
Tx of Acute Otitis Media in Children
* acetaminophen or ibuprophen for pain * antihistamines & decongestants NOT effective in children unless allergies * NO OTC COLD MEDS if \<6 * Auralgan drops OTC * Tx or watchful waiting: * \<6 mo OR 6mo-2yr w/ bilateral OM - treat * 6mo-2yr w/ unilateral - observe 48-72hr or treat * 2+yr - treat is severe symptoms, if mild can observe w/ follow-up and agreement b/t parents and HCP * Abx: * Amoxicillin 90mg/kg divided 2 doses (max 3gm/d) unless: * given in last 30 days (resistance) * concurrent purulent conjunctivitis * PCN allergy * Cefdinir
64
Tx of Otitis Media in Adults
* Amoxicillin 875 mg PO BID -or- 500mg TID 5-7d / 10d if severe * if PCN allergy: * Azithromycin (Z-pak) 500mg on day 1, then 250mg days 2-5 * Clarithromycin 500mg bid
68
Chronic OM Tx
* keep ear dry, cleaned/debrided, granulation tissue removed * topical corticosteroids and abx * systemic abx and surgery for severe cases only * attic perforations or chronic central TM- tympanoplasty * cholstesteatoma or mastoid invovlement w/ TM perf- mastoidectomy and tympanoplasty
71
* SERIOUS: abnormal replacement of normal bone with sponiotic or sclerotic bone- leads to fixation of stapes to margins of oval window * results in progressive **_bilateral_** conductive hearing loss * strong genetic inheritance * mostly caucasians and 2x more likely in females
Otosclerosis * Dx: * hx, audiogram, progressive conductive HL * exacerbated by pregnancy and estrogen therapy * often presents in 3rd decade of life * Tx: * hearing aids (temporary) * surgery: total/partial stapedectomy
72
Leukopenia pre-malignant lesion * white keratotic plaque that cannot be wiped away * may show dysplasia
73
Erythroplakia premalignant lesion * red plaque-like lesion with HIGHER risk of developing into oral cancer than leukoplakia * more likely to occur on buccal & mandibular mucosa, palate, tongue, floor of mouth- may show dysplasia
74
Oral Cancer Exam
* if SMOKER/DRINKER and mouth/neck issues keep CA in differential * cervical lymph node enlargement * difficulty speaking if tongue affected * numbness of chin if lesion on lip and affects mental nerve
75
Features Suggestive of Oral Cancer
* **tooth mobility of unknown cause\*\*** * **non-healing dental extraction site\*\*** * unexplained ulceration * unexplained red and white patches that are painful, swollen, bleeding * unexplained ear pain/neck pain - esp. w/ limited mouth opening but normal otoscopy * irregular pigmented mucosal areas (suggestive of melanoma) * tongue numbness or fixation * TX: * referral to dentist
76
Geographic Tongue (benign migratory glossitis) Non-cancerous lesion * cause unknown (may be linked to psoriasis) * Tx: * no tx necessary and not contageous
77
Torus Palatinus Non-cancerous lesion * bony prominance of the hard palate- composed of bone, linked to genetics * Tx: * surgically removed if causes pain or discomfort
79
Paranasal Sinus Cancer * CA usually affecting maxillary sinuses (sometimes ethmoid), uncommon * Risks: chem exposure/pollution, tobacco, HPV * Dx: * looks like sinusitis or asymptomatic * facial pain, dental pain, nasal obstruction, epistaxis- perisistant/chronic * CT of mass * Tx: * surgical resection (endoscopic) * radiation (sometimes chemo)
80
* Risk: * acohol, tobacco, **HPV infection** (16,18,31,33) * young men if no alc/tob, mult sexual partners * S/s: * dysphagia * throat pain/fullness * oral bleeding * referred ear pain * voice changes * **2 WEEK time limit on throat pain/symtoms**
Orophryngeal Cancer
86
* cancer associated with salted/cured foods, Chinese herbs, rancid butter/sheep's fat and my be triggered by reactivation of EBV * In US/Europe associated with tobacco and alcohol use (maybe HPV) * S/s (triad): * neck mass * serous OM and resultant hearing loss / tinnitis * nasal obstruction or pain * Tx: * referral to ENT * CT, small mirror/nasophayngoscope visualization, biopsy
Nasopharyngeal Cancer
89
Diagnosing Tumors of Head & Neck
* Thorough Hx: * tobacco and alcohol use especially * length of symptoms (normal throat pain/symtoms resolve in 2 weeks) * fatigue, weight loss, appetite loss/dysphagia, spread to other organs * Complete physical: * Full HEENT and oral exam * Full lymphantic system exam * Full cardiovascular and respiratory exam * ENT referral * CT -\> panendoscopy -\> biopsy -\> Tx based on TNM staging (tumor, lymph node, metastases)
90
Infection & Allergy Symptoms
* Bacterial * mild/moderate pain, red eye, foreign body sensation, purulent discharge, glued eyes on awakinging, unilateral * Viral * no/mild pain, gritty sensation, watery discharge, unilateral, upper respiratory infection (URI) * Herpes * pain and tingling followed by rash and conjunctivitis * Allergic * BILATERAL, tearing, intense itching, stringy discharge, diffuse hyperemia
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Infective Agents
* Bacterial * S. pneumoniae, H. flu, S. aureus, chlamydia, gonorrhea * Viral * adenovirus, herpes zoster * Contact lenses - pseudomonas
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Viral Tx
* No meds usually * **NO STEROIDS**- prevent healing, glaucoma risk * cold compresses * ocular decongestants to reduce redness (avoid) * oxymetazoline, tetrahydozoline (eg. Visene) * artificial tears * Herpes: * trifluridine drops (Viroptic) * oral antivirals for systemic infections
93
Bacterial Tx
* normally self-limiting and resolve within a week (except gonorrhea) * think about what is most likely to cause infection, cost, friendliness of course * Gentamicin/Tobramycin toxic- but may need to be used b/c G- * Frequent: * Moxifloxacin
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Allergic Conjuntivitis Tx
* Antihistamines: * Azelastine (Optivar) * Emedastine (Emadine) * Ketotifen (Zaditor, Alaway, etc) OTC * Mast cell stabilizers * not as effective
95
Ocular NSAIDs & Steroids
* NSAIDs: * block COX-1 (platelett aggregation) & COX-2 (pain, inflammation) * use: opthalmic procedures post op * SE: delayed woud healing, keratitis, reactivate HPV * Steroids: * block phospholipase A2 -\> blocks COX-1 & COX-2 * opthalmic injury, post op, anterior uveitis * SE: do not use if infection (may cause), glaucoma/nerve damage/cataracts, increased intraocular pressure, delayed healing, no contact wear with loteprednol
96
Glaucoma Tx
* prostaglandin analogs * reduce IOP via increases **uviscleral** outflow in open-angle glaucoma * SE: * increased/misdirected eyelash growth, herpes activation, allergy, hyperpigmentation, migrane, keratitis * Rx (1x at night): * Latanoprost (Xalatan) * Bimatoprost (Lumigan) * Travoprost (Travatan Z) * Tafluprost (Zioptan) * Beta-blockers * **decrease beta-receptor** stimulation production of aqueous humor * SE: allergy, keratitis, systemic effects (cardio) * Rx (BID): * Betaxolol (Betoptic-S) ◦Far more selective for beta-2 * Timolol (Betimol, Istalol, Timoptic, Timoptic-XE) ◦Non-selective ◦Short-term escape, long-term drift * Carteolol * Levobunolol (Betagan) * Metipranolol

Clinical Medicine I (8 decks)

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