EENT Flashcards
ectropion
eyelid + lashes turned outward (relaxed orbicularis oculi)
-mc bilateral elderly, but can be congenital, infx or CN7 palsy
entropion
eyelid + lashes turned inward (spasms of orbicularis oculi)
-mc in elderly
dacrocystitis
infx of lacrimal sac
- mc s. aureus, strep
- redness to medial canthal (nasal side) of lower lid
blepharitis
inflam of both eyelids - common in down’s + eczema
- anterior (skin + base of eyelashes) - infx or seborrheic
- posterior - meibomian gland dysfunction (rosacea or allergic derm)
- tx - eyelid hygiene, compress, massage (posterior), abx if unresponsive
chalazion
painless lipogranuloma of either a meibomian gland or a Zeis gland
- eyelid lump/swelling, nontender
- hygiene, compress, abx not necessary, cortico injection or incision if large/affecting vision
pterygium
triangular-shaped, “growing”, fibrovascular mass - nasal side of eye
- assoc w/ inc UV exposure, sand, wind, dust
- observe, remove if vision affected
pinguecula
yellow, elevated nodule on nasal side of sclera (fat/protein)
- doesnt grow!
- observe, cosmetic removal
orbital floor “blowout” fracture
- decreased vision, diplopia esp w/ upward gaze (if inferior rectus entrapped), epistaxis, dyesthesias, hyperalgesia or anesthesia to cheek (due to infraorbital nerve)
- nasal decongestant (dec pain), abx, corticosteriords, surgical repair
macular degeneration
rf: >50yo, caucasian, F, smoker
- mc cause of permanent legal blindness in elderly >75yo
- macula responsible for central vision and detail/color
-MC dry (atrophic) type: gradual breakdown; DRUSEN = small, round, yellow-white spots on outer retina (accum of waste products)
-wet (neovascular or exudative): new, abnormal vessels grow under central retina and leak blood –> scars
(rare and faster progression)
-sx: bilateral blurred or loss of central vision (detail/color), scotomoas (blind spots), metamorphosia (straight lines appear bent), micropsia (objects look smaller)
diabetic retinopathy
- mc cause of new, permanent vision loss/blind 25-74yo
- glycosylation of collagen of BV –> capillary wall breakdown–> ischemia, edema
Nonproliferative (background): microaneurysms (cotton wool spots, hard exudates, blot + dot hemorrhages)
-tx: panlaser tx, strict glucose control
Proliferative: neovascularization (new BV), vitreous hemorrhage
-tx: VEGF inhibitors (bevacizumab), laser photocoag tx, glucose control
hypertensive retinopathy grades
I: arterial narrowing –> copper wiring (mod), silver wiring (sev)
II: AV nicking - venous compression at arterial-venous jx by increased arterial pressure
III: flame-shaped hemorrhages, cotton wool spots
IV: papilledema (malignant HTN)
retinal detachment
Rhegmatogenous MC type: retinal tear –> retinal inner sensory layer detaches from choroid plexus
- mc predisposing factors: myopia + cataracts
- sx: photopsia (flashing lights) –> floaters –> progressive unilateral vision loss (curtain coming down) in periphery initially –> central vision loss
- dx: fundoscopy = retinal tear, +shafer’s sign (clumping of brown pigment cells in anterior vitreous humor (“tobacco dust”)
- OPTHO EMER - keep supine, no drops –> laser, cryotherapy, ocular sx
chemical burns (eye)
OPTHO EMER - immediate irrigation
- alkali worse than acid (liquefactive necrosis vs. coagulative necrosis)
- irrigate w/ lactated ringers or normal saline; LR ph higher and closer to tears (pH 7.1) x30 min, at least 2L
- check pH and visual acuity after irrigation
- abx like moxifloxacin + 0.25% atropine drops (cycloplegic agent), optho f/u
periorbital cellulitis
- usually 2ry to sinus infx, ethmoid mc
- mc children
- DECREASED VISION, pain w/ eye movement, proptosis (eye bulge), erythema + edema
- dx - CT scan
- tx - IV abx - cover for STAPH/MRSA - vanc, clinda, cefotaxime, amp/sulbactam
preseptal cellulitis - infx of eyelid and periocular tissue, pain/swell but NO VISUAL CHANGE and NO PAIN w/ MOVEMENT
-tx- amox/clav
keratitis (corneal ulcer/inflam)
- bacterial mc, pseudomonas, acanthamoeba (contacts)
- sx: pain, photophobia, reduced vision, red, tearing
- bacterial: hazy cornea, ulcer –> FQ drops, no patch!
- HSV: dendritic lesions (branching w/ fluoro stain) –> topical antivirals
anterior uveitis (iritis)
inflam of iris or ciliary body (cyclitis)
- systemic inflam dz (esp if reocurrs) or infectious
- unilateral pain/red/photophobia, usually after trauma
- ciliary injection (limbic flush), consensual photopohobia, inflammatory cells and flare w/in aq humor
-tx- topical corticosteroids, scopolamine, topical cycloplegics to relieve pain
posterior uveitis
choroid inflammation
- blurred/decreased vision, floaters, no pain, no sx of anterior involvement
- ciliary injection (limbic flush), consensual photopohobia, inflammatory cells and flare w/in aq humor
-tx- systemic corticosteroids
RF for cataracts
aging (mc >60), smoker, corticosteroids
DM, UV light, malnutrition, trauma
-congenital: ToRCH syndrome (toxoplasmosis, rubella, CMV, HSV)
papilledema
optic nerve (disc) swelling 2ry to increased intracranial pressure (bilat)
- mc idiopathic intracranial HTN
- space-occupying lesion, inc CSF, cerebral edema, malignant/sev HTN
- sx- HA, N/V, vision preserved but maybe changes
- exam- swollen optic disc, blurred margins
- MRI/CT to r/o mass effect; LP for inc CSF
- tx- diuretics (acetazolamide - dec production of aq humor and CSF)
optic neuritis (optic nerve CN2 inflam)
acute inflam demylination of optic nerve
- mc young 20-40yo
- MULTIPLE SCLEROSIS mc, meds - ethambutol, chloramphenicol
- loss of color vision, central scotoma/blind spot, usually unilateral, loss of vision over a few days
- ocular pain that is worse w/ movement
MARCUS-GUNN PUPIL (positive)
-tx: IV methylprednisolone, followed by oral corticosteroids
acute narrow angle-closure glaucoma
decreased drainage of aqueous humor in pt w/ preexisting narrow angle or large lens (elderly, far-sighted, asians)
- preciptating factor = mydriasis (pupil dilation futher closes angle) like dim lights, sympathomimetics and anticholinergics
- sx - severe, sudden, UNILATERAL ocular pain, vision changes, halos around lights, tunnel vision
- exam - conjunctival erythema, steamy cornea, mid-dilated, fixed, nonreactive pupil, cupping of optic nerve via fundo
- tx- lower IOP (acetazolamide) and open angle (cholinergics), topical BB
chronic (open angle) glaucoma
slow, progressive BILATERAL vision loss
- normal anterior chamber and angle, reduced aqueous drainage through trabeculum
- RF: AA, >40yo, fam hx, DM
- sx- painless, tunnel vision –> central loss
- exam- cupping of optic discs (inc ratio)
- tx- prostaglandin analogs 1st line, BB, a-2 agonists; laser tx if fails
central retinal artery occlusion (CRAO)
retinal artery thrombus or embolus
- mc 50-80yo w/ atherosclerotic disease; OPTHO ER
- sx- acute, sudden monocular vision loss, often preceded by amaurosis fugax
- dx- pale retina w/ cherry-red macula (red spot) due to obstx; “box car” appearance of retinal vessels
- tx- decrease IOP, revascularize by laying supine and orpital massage to dislodge clot
central retinal vein occlusion (CRVO)
central retinal vein thrombus –> fluid backup in retina
- RF: HTN, DM, glaucoma, hypercoagulable
- sx- acute, sudden, monocular vision loss
- exam- extensive retinal hemorrhages (blood + thunder appearance), macular edema, optic disc swelling
- tx- +/- antiinflammatories, steroids, laser photocoag
mastoiditis
usually complication of prolonged/untreated otitis media
- sx- deep ear pain (worse at night), F, mastoid tenderness
- complications- hearing loss, vertigo, CN7 paralysis, abscess
- dx- CT scan
- tx- IV abx + middle ear/mastoid drainage (myringotomy)
etiologies of conductive hearing loss
CERUMEN IMPACTION MC
external or middle ear - defect in sound conduction (obstx of object or cerumen), damage to ossicles (otosclerosis, cholesteatoma), mastoiditis, OM
etiologies of sensorineural hearing loss
PRESBYACUSIS MC (natural aging) internal ear disorders - presbyacusis, chronic loud noise exposure, CNS lesions (acoustic neuroma), labyrinthitis, Meniere's syndrome
TM perforation
mc due to penetrating or noise trauma (mc occurs at pars tensa), otitis media
-may lead to cholesteatoma devo
+/-conductive hearing loss
-most heal spontaneously
-avoid water/moisture, no topical aminoglycosides
cholesteatoma
abnormal keratinized collection of desquamated squamous epithelium –> mastoid bony erosion
- granulation tissue that erodes the ossicles over time –> conductive hearing loss
- sx- painless otorrhea (brown/yellow w/ strong odor) +/- vertigo/dizzy
- dx- granulation tissue/cellular debris +/- perf of TM, vertigo, conductive hearing loss
- tx- surgical excision and reconstruction of ossicles
otosclerosis
abnormal bony overgrowth of stapes –> conductive loss
- sx- slowly progressive hearing loss, tinnitus
- tx- stapedectomy w/ prosthesis
benign paroxysmal positional vertigo
sudden, episodic, provoked by change of head position
- usually lasts 10-60 seconds
- pos DIX-HALLPIKE TEST/NYLAN BARANY –> fatigable, horizontal nystagmus
- tx- EPLEY maneuver; antihistamines
vestibular neuritis
inflam of the vestibular portion of CN8
- MC after viral infx
- sx- peripheral vertigo (continuous), dizzy, N/V, gait disturbances; +/- horizontal nystagmus, away from affected side
- tx- CORTICOSTEROIDS, antihistamines for symptoms
labyrinthitis
vestibular neuritis + hearing loss/tinnitus
- sx- cochlear involvement so hearing loss + continuous peripheral vertigo, dizzy, N/V, gait disturb, horiz nystagmus
- tx- CORTICOSTEROIDS
meniere’s disease (idiopathic endolymphatic hydrops)
idiopathic distention of endolymphatic compartment of inner ear by excess fluid –> increased pressure –> hearing and balance disorders
- sx- episodic vertigo lasting min-hours, tinnitus, ear fullness, fluctuating hearing loss
- dx- transtympanic electrocochleography during active
- tx- symptomatic - antihistamines, anticholinergics, benzos; decompress if refractory or severe
- prevent- diuretics reduce endolymph pressure, avoid salt/caffeine/chocolate/ETOH (bc inc endolymph pressure)
*meniere syndrome due to identifiable cause, meniere disease is idiopathic
acoustic (vestibular) neuroma
CN8 / schwannoma - benign tumor of schwann cells
- sx- gradual hearing loss unilateral, tinnitus, balance disturbance (not episodic)
- dx- MRI
sinusitis area frequency
maxillary > ethmoid > frontal > sphenoid
peritonsillar abscess
tonsillitis –> cellulitis –> abscess formation
- mc strep (then staph, polymicrobial)
- sx- muffled “hot potato voice”, diffulty w/ oral secretions, trismus, UVULA DEVIATES to CONTRALATERAL SIDE
- dx- CT scan differentiate cellulitis vs abscess
- tx- abx + aspiration or I+D (ampicilin/sulbactam) - tx clinically if not worried about deep neck involvement
oral leukoplakia
precancerous hyperkeratosis due to chronic irritation (tobacco, smoking, ETOH, dentures)
- sx- painless, white patches can’t be scraped off
- tx- cryotherapy, laser ablation, biopsy for cancer risk
erythroplakia
precancerous lesions similar to leukoplakia but w/ erythematous appearance
*90% is either dysplastic or evident of SCC
oral hairy leukoplakia
caused by EBV (human herpes virus 4)
- mc in immunocompromised
- painless, white plaque along lateral tongue or buccal mucosa +/- smooth or irregular “hairy” lesions, can’t be scraped off, may change appearance daily
- tx- no tx required, may spont resolve, antiretroviral tx
sialothiasis
mc in wharton’s duct (submandibular); stensen’s duct
- postpranidal salivary gland pain/swell
- tx- sialogogues, increased fluids, massage; avoid anticholinergics –> lithotripsy
acute bacterial sialadenitis (suppurative sialadenitis)
bacterial infx of parotid or submanibular salivar glands
- STAPH MC, dehydration, chronic illness
- sx- pain, swell, erythema near gland esp w/ meals, tenderness at opening, +/- puss if massaged
- dx- CT SCAN (for associated abscess/extent)
- tx- sialogogues, abx (dicloxacillin or nafcillin)
oral lichen planus
idopathic cell-medicated autoimmune response (inc in pt w/ HCV infx)
- sx- lacy leukoplakia of oral mucosa (wickham striae)
- tx- local or systemic corticosteroids
acute herpetic gingivostomatitis
primary manifestation of HSV-1 in children (mc 6mo-5y)
-sx- sudden onset F, anorexia –> gingivitis
vessicles on oral mucosa (gray/yellow lesions)
-tx- usually self-limiting, acyclovir if severe
actue herpetic pharyngotonsillitis
primary manifestation of HSV-1 in adults
- sx- F, malaise, HA, sore throat, vesicles that rupture –> ulcerative lesions w/ grayish exudates in post pharynx
- tx- oral hygiene, resolve 1-2 wks
ludwig’s angina
cellulitis of sublingual and submaxillary spaces in neck
- MC 2ry to dental infx (anaerobes)
- sx- swelling/erythema of upper neck and chin w/ PUS ON FLOOR OF MOUTH
- dx- CT SCAN
- tx- AMP/SULBACTAM (unasyn) or PCN + metro or clinda
tinnitus
Evaluation should include a review of the patients blood pressure, allergies, serum lipids and thyroid function. Since most cases are due to presbycusis (age-related, cumulative hearing damage and loss), effective therapies are limited. Medication management involves trials of diuretics, antihistamines, anticonvulsants, tricyclic antidepressants and benzodiazepines.
Acoustic neuroma: CN VIII, hearing loss + tinnitus + disequilibrium
Ménière disease: recurrent vertigo + tinnitus + hearing loss
Ramsay Hunt syndrome: facial paralysis, zoster lesions, tinnitus
Labyrinthitis: sudden severe vertigo, hearing loss, tinnitus, not recurrent
Head trauma
Electrical injury
Diving
Ototoxic agents:
Salicylates: respiratory alkalosis + anion gap metabolic acidosis + tinnitus
NSAIDs
Quinine
ABX (aminoglycosides, erythromycin, vancomycin)
Chemotherapeutic agents
sinusitis classification / duration
< 4 weeks - acute
subacute
>12 weeks - chronic
Retropharyngeal Abscess
Patient will be a toxic-appearing child 3–5 years-old w/ hx of trauma or URI
- sx- fever, sore throat, dysphagia, trismus, stridor, nuchal rigidity, muffled voice, cri du canard (duck “quack”)
- neck X-ray will show widened retropharyngeal space twice the size of the vertebral body
- dx- CT scan
- MC S. aureus, group A streptococcus, anaerobes, foreign body
- tx- intravenous antibiotics, +/- I+D
