EENT Flashcards
History
- frequent colds, nasal stuffiness, nasal discharge, sinus trouble, head pain, hay fever, nosebleeds, sense of smell, unusual odors
- past or present trauma
Physical Exam
A. inspect for deformity, asymmetry, inflammation
B. inspection through anterior naris
1. limited to vestibule, anterior septum, lower and middle turbinate
C. tilt patient’s head back, insert otoscope
1. inspect mucosa
a. color (pink), edema, exudates, bleeding
i. red, swollen - rhinitis (bacterial or viral)
ii. pale, swollen - allergies
2. septum
a. deviation, bleeding, perforation
3. lower and middle turbinates
a. color, swelling, exudates, polyps
D. palpation
1. frontal sinuses
a. middle and medial supra-orbital ridge
2. maxillary sinuses
a. maxilla - under eyes
Testing
A. cultures of nasal discharge
B. x-rays, CT scans of sinuses
Emergencies
A. epistaxis if severe
1. usually associated with liver disease
B. fractures if nasal bones displaced
Epistaxis: nosebleed
- etiology
- trauma
a. digital (nose picking)
b. fractures - local infections
- systemic infections
- drying of membranes
- atherosclerosis
- hypertension
- liver disease
- diseases with bleeding tendencies
a. **leukemia (often first sign you see in kids), thrombocytopenia, aplastic anemia
-(Hypertension + atherosclerosis + drying of membranes = epistaxis, often not isolated)
Epistaxis
- treatment
- stop bleeding
a. pinch ala nasi together for 5-10 minutes
b. cotton pledget
c. cauterization - find and tx underlying cause
Rhinitis
- definition
acute URI with edema of nasal mucous membrane, nasal discharge, and obstruction
Rhinitis
- etiology
- respiratory viruses
- bacteria
a. streptococcus (pneumoccal and pyogenes), staphylococcus
Rhinitis
- signs and symptoms
- diagnosis
- nasal discharge
- nasal obstruction
- erythematous, edematous mucosa
- culture and sensitivity
Tx - antibiotics, topical vasoconstrictors, increase fluids, Vit C, Vit A, Zinc
Allergic Rhinitis
- signs and symptoms
- may be seasonal due to wind-borne pollens
- sneezing, rhinorrhea, congestion, pruritis (itching)
- pruritis of nose, mouth, pharynx, and eyes
- lacrimation, sneezing, watery nasal discharge
- frontal HA, irritability, anorexia, depression, insomnia
- injected conjunctiva
- swollen, pale, or gray nasal mucosa (starts pale, becomes red)
- dx by history and eosinophils in nasal secretions
- tx with oral antihistamines
- cromolyn sodium for prevention
- desensitization
Sinusitis
- definition
inflammation in paranasal sinuses due to viral, bacterial, fungal infections or allergic reactions
Sinusitis
- classification
1. Acute
A. Less than 4 weeks in duration
2. Subacute
A. 4-12 weeks in duration
3. Chronic
A. 3 months or longer in durationSinusitis
- etiology (acute and chronic)
- acute
a. preceded by viral uri
b. strep, staph, hemophilus - chronic
a. 25% due to (undiagnosed) dental infections
Sinusitis
- signs and symptoms
- tender and swollen over the sinuses
- frontal pain and HA
- facial pain, HA, toothache
- loss of smell
- halitosis - (infection in sinuses)
- erythematous, edematous nasal mucosa
- mucopurulent nasal discharge
- decreased transillumination
Sinusitis
- testing
- culture and sensitivity of discharge
- x-rays
a. of sinuses and apices of teeth (R/O periapical abscess) - CT scan
a. better definition of extent and degree of infection
b. polyps
Tx - antibiotics, eliminate food sensitivities, Vit C, Vit A, Zinc, Steam inhalation, Revulsive hydrotherapy to face, sinus wash
PHARYNX
- history
A. problems in mouth, sores, sore tongue, condition of teeth and gums, bleeding gums, unusual or bad tastes, sore throats, hoarseness, difficulty swallowing, “swollen glands” in neck
- (aphthos ulcers, could be indicative of infection of their areas of GI)
PHARYNX
- physical exam
A. inspect lips, gums, teeth, buccal mucosa, tongue for color, masses, bleeding, edema, ulceration
B. visualize pharynx with tongue depressor
1. soft palate, uvula, anterior and posterior tonsillar pillars, tonsils, posterior pharynx
C. palpate lymph nodes
1. pre and post auricular, occipital, tonsillar, submaxillary, submental, superior cervical, posterior cervical, deep cervical, supraclavicular
a. size, tenderness
PHARYNX
- testing
- culture and sensitivity — “really pretty simple, swab”
PHARYNX
- emergencies
A. Epiglottitis
1. Severe pain on swallowing, breathing difficulty
*never stick anything in pt’s mouth if you suspect this! Epiglottis could spasm and lock down.
Pharyngitis
- definition
- etiology
A. Inflammation of the pharynx
- usually viral - most likely, we don’t really know
- group A Beta hemolytic streptococcus pyogenes (pathogenic form of strep throat)
a. beefy red pharynx with exudates (pus)
i. in 20% of patients with strep
ii. others asx or mild sxs
- could get glomerular nephritis
b. scarlet fever
i. strep produces erythrogenic toxin
ii. diffuse pink-red rash over abdomen, lateral chest, skin folds
iii. strawberry tongue
iv. Pastia’s lines
Pharyngitis
- signs and symptoms
- sore throat, pain on swallowing, (if more bacterial) —> fever, cervical lymphadenopathy
Pharyngitis
- lab
- leukocytosis (with neutrophilia)
a. left shift if strep - rapid strep test, still some false positives and false negatives (if pos, always do a culture; if negative, maybe do a culture)
- culture for strep if rapid test negative but suspect still suspect strep
Tx -
- none if viral
- antibiotics (penicillin, amoxicillin, erythromycin) if strep
a. to prevent rheumatic fever, glomerulonephritis - vit. C, vit. A (if no liver issues), zinc (if cigarette smoker, no beta carotene)
- revulsive hydro to neck - alt hot and cold, so easy to get to the neck
- hydrastis
- Rub lymph nodes down to assist with drainage (firm, slow)
Tonsillitis
- definition
- etiology
A. inflammation of the tonsils
B. etiology
1. strep - “true tonsillitis caused by strep” 2. sometimes viral
Tonsillitis
- signs and symptoms
- sore throat, pain on swallowing often referred to ears (sharp pain that radiates to the ears - differentiate from pharyngitis)
- high(er) fever, HA, malaise, vomiting
- (used to be able to diagnose by peeling off exudate, “if peels off, strep tonsillitis”) - tonsils edematous and erythematous
- purulent exudate
- membrane on tonsils that peels away without bleeding
Tonsillitis
- laboratory and treatment
Same as pharyngitis —
- leukocytosis (with neutrophilia)
a. left shift if strep - rapid strep test, still some false positives and false negatives (if pos, always do a culture; if negative, maybe do a culture)
- culture for strep if rapid test negative but suspect still suspect strep
Laryngitis
- definition
- etiology
A. inflammation of the larynx
- viral uri most common cause
- bronchitis, influenza, pneumonia, pertussis, measles, diphtheria
- excess use of voice
- cigarette smoke or inhalation of other irritants
- allergic reaction - (any kind of allergies)
- GERD (- fluid from stomach travels up and causes larynx to spasm, even if person taking PPI)
Laryngitis
- signs and symptoms
- unnatural change of voice
- hoarseness, aphonia
- tickling, rawness, urge to clear throat
- fever, malaise, pain, dyspnea if severe
Laryngitis
- diagnosis
- Indirect laryngoscopy
Tx-
- voice rest
- steam inhalation
- neutralize xs HCl
- as in pharyngitis, (if pharynx involved)
Infections Mononucleosis
- definition
- etiology
A. viral infection causing fatigue, fever, pharyngitis, lymphadenopathy
- EBV - Epstein Barr (lives in body for life, mostly in dorsal root ganglia)
- CMV - cytomegalovirus
Infectious Mononucleosis
- epidemiology
- found in 50% children under age of 5
- persists for life
- most common between ages of 15 – 17, college freshman
- commonly transmitted by kissing asx individual
Infectious Mononucleosis
- signs and symptoms
- fatigue, HA, sore throat, fever
- myalgia
- loss of appetite
- hepatomegaly, *splenomegaly — (palpate abdomen, spleen)
(- red and swollen tonsils
- exudates bigger, whiter, more irregular (but wont always be so clear))
Infectious Mononucleosis
- diagnosis
- leukocytosis
a. atypical lymphocytes - monospot - (specific for mono virus (type of heterophile antibody test))
a. heterophile antibodies
i. positive one week after sxs begin
b. antibody titer for EBV — )$$, don’t really need)
Tx - - support liver, spleen - anti-viral (acyclovir) (- rest, rest, rest) (Illness stuck in the Shaoyang stage, TB 5, GB 41, Xiao Chai Hu Tang — Joe does this if seeing someone at early stages, plus high doses Vit C, licorice, etc)
EAR
- history
- hearing, ringing, noises, drainage, infections, spinning sensation
EAR
- physical exam
A. inspection of the auricle
B. palpate tragus
C. palpate mastoid process
D. otoscope to inspect tympanic membrane - pneumatic
1. malleus, cone of light, color, fluid levels
E. auditory acuity
1. whispers, fingers rubbing, watch ticking
(- have pt close eyes, lightly snap fingers on either side of the ears (one at a time, slowly moving closer in towards the ear), which ear do they hear it out of)
EAR
- testing
A. Audiometry - quantitates hearing loss (hearing level in decibels, better way to figure out which kind of hearing aid you need)
EAR
- emergencies
A. ear trauma 1. fractures of temporal bone B. sudden severe ear pain - perforation C. acute hearing loss D. discharges E. vertigo 1. must distinguish between peripheral and central
Otitis Externa
- definition
- etiology
A. Infection in the (external) ear canal
1. Swimmer’s ear
- Bacteria
- Water, hair spray, trauma from cleaning the canal
Otitis Externa
- signs and symptoms
- pruritis, pain, foul-smelling discharge
- possible hearing loss from blockage of canal
- tenderness on traction of pinna & pressure on tragus
- skin of canal may be red, swollen, moist
(palpate the tragus or traction the pinnacle superior (with adults) and posterior — go inferior with children)
Tx-
1. Topical antibiotics
(Garlic oil great for this — unless perforation of membrane, do not use whole clove of garlic)
Otitis Media
- definition
- etiology
A. Bacterial or viral infection in middle ear (close to chamber except for Eustacian tube)
1. Often secondary to URI
- Bacteria and viruses
A. Pneumo, strep, staph, hemo
Otitis Media
- classification
- AOM – acute otitis media
a. 2 weeks duration - OME – otitis media with effusion
a. fluid behind tympanic membrane after infection - COME – chronic otitis media with effusion
a. fluid remains or returns (more than 2 weeks + fluid) - recurrent OM
a. 4 episodes in 6 months or 6 episodes in 1 year
Otitis Media
- signs and symptoms
- earache – pulling at ears
- fever
- possible hearing loss
- erythematous, bulging tympanic membrane with loss of landmarks and light reflex (no cone of light)
- possible perforation
Otitis Media
- diagnosis
- clinical
- complications
a. mastoiditis, labyrinthitis, facial paralysis, hearing loss, meningitis, brain abscess
Serous Otitis Media
- definition
A. effusion in middle ear from otitis media
B. eustachian tube may be blocked from inflammation or allergies
Serous Otitis Media
- signs and symptoms
- retraction of tympanic membrane
- accentuated landmarks and diminished light reflex
- amber or gray fluid in middle ear
- fluid or air bubble levels
Tx - antibiotics, myringotomy (tympanostomy), food sensitivities, tx as in Otitis media
Mastoiditis
- definition
A. Bacterial infection in mastoid process
1. Coalescence of mastoid air cells (bone has many air cells, susceptible to bacterial infection, coalesce)
Mastoiditis
- etiology
- Bacteria as in otitis media
2. Untreated acute otitis media
Mastoiditis
- signs and symptoms
- usually more than 2 weeks after untreated otitis media
- erythema, edema, tenderness, fluctuation (soft and squishy) over mastoid process
- auricle (usually) displaced laterally and inferiorly
- persistent, throbbing pain
- hearing loss increasing - getting worse progressively over time
(- **urgent, almost an emergency
- usually happens in the ear that hasn’t healed, if otitis media in both ears, prone to this in both mastoid processes)
Tx - antibiotics
Meniere’s Disease
- definition
A. Recurrent vertigo, sensory hearing loss, tinnitus (lots and lots of vertigo)
1. With endolymphatic hydrops
Meniere’s Disease
- etiology
- unknown
- head injuries
- otitis
- viral infections
- alcohol use
Meneire’s Disease
- signs and symptoms
- sudden vertigo
a. lasts 1-24 hours
b. gradual subsidence - fullness or pressure in affected ear
- hearing loss worsens progressively over years
- constant or intermittent tinnitus
- usually unilateral
a. 10-15% bilateral
Meniere’s Disease
- diagnosis
- clinical
- caloric stimulation tests
- CT scans
a. RO other causes of sxs
Tx- diuretics(hydrochorothiazide), low salt diet, surgical, food sensitivities, manipulation
EYE
- history
A. vision, glasses or contacts, last eye exam
B. glaucoma, cataracts
C. blurred vision, double vision (diplopia)
D. pain, redness, watery eyes, discharge, blind spots “floaters”
EYE
- physical exam
A. eyelids, lacrimal apparatus
B. PERRLA (pupils equal round, reactive to light, and accommodative - constrict and dilate) — if all of this is normal, chart as PERRLA
C. extraocular movements - H and X in space - make sure muscles all work, also neurological exam — chart as EOMI = Extra ocular movements intact
D. visual fields
E. fundoscopic exam
EYE
- testing
A. visual acuity - eye chart
B. fluoroscein dye - corneal abrasions green (e.g. scratch on cornea)
C. ultrasound - (not done often)
1. retinal tumors, detachments, vitreous hemorrhages
D. tonometry (measuring pressures) - like a fishing scale but opposite, run risk of scratching cornea and infection
- should be done on a regular basis
EYE
- emergencies
A. *foreign bodies that penetrate the globe
B. trauma to the globe
C. acute visual loss or disturbance
D. sudden severe pain
E. uveitis - uveal tract (ciliary body that holds the lens, retina, and choroid plexus, iris)
F. retinal detachment
Dacryocystitis
- definition
A. Infection of the lacrimal apparatus
B. Usually secondary to obstruction of nasolacrimal duct
1. Can be congenital dacrostenosis, trauma, deviated septum (common), rhinitis, polyps
Dacryocystitis
- signs and symptoms
- pain, erythema, edema around sac
- watery eyes, conjunctivitis, blepharitis, fever
Tx - hot packs, antibiotics, nasolacrimal dilation
Blepharitis
- definition
- etiology
A. inflammation of lid margins (right where eyelashes are, can come from dacryocystitis)
B. etiology
1. bacteria - staph 2. seborrhea (A skin condition that causes scaly patches and red skin, mainly on the scalp)
Blepharitis
- signs and symptoms
- *pruritis, edema, erythema, burning, loss of lashes, *lacrimation, *photophobia
Tx - recurrent and resistant to treatment; improved lid hygiene; antibiotic ointment
Hordeolum
- definition
A. stye B. localized infection of glands in lids 1. external a. Zeis or Moll glands at hair follicles 2. internal a. meibomian glands on inside of lids
Hordeolum
- signs and symptoms
D. sxs & sns
1. external a. superficial, at base of eyelash, (hard) b. pain, redness, tenderness of lid margin c. small, round, tender induration d. lacrimation, photophobia 2. internal a. deeper, seen through conjunctiva b. localized pain, redness, edema c. elevation or yellow area on conjunctival side of lid
Tx- hot compresses (golden seal, berberry, Oregon grape)
