EENT Flashcards
Conjunctivitis
Path:
Pt:
Tx:
Path:
- Bacterial S pneumo, Staph, pseudomonas (contact lense), haemophilus, M cat, gonorrhoeae, chlamydia
- Viral: adenovirus
- Allergic
Pt: Erythematous conjunctiva
- Bacterial: mucopurulent discharge, matting/swelling of eyelid, foreign body sensation
- Viral: watery discharge
- Allergic: thin clear discharge, pruritic, bilateral
Tx:
- Bacterial: Polymyxin-bacitracin, sulfacetamide, erythromycin, fluoroquinolone
- Viral: warm compresses, antihistamine, mast cell stabilizers
- Allergic: vasoconstrictor + antihistamine gtt (naphazoline-antazoline), mast cell stabilizer: lodoxamide
Cataract Path: Pt: Dx: Tx:
Path: Opaque ocular lens (thickening) 2/2 age (senescent), cigarette smoking, trauma, steroids, degenerative eye disease, prematurity
Pt:
Gradual blurring of vision, usually a fog over the eye
+/- rings/halos around objects, vision may appear more blue or yellow
Dx: Clx
Visual acuity exam
Absent red reflex
Tx:
Surgery vs glasses
Corneal ulcer Path: Pt: Dx: Tx:
Path: Infection 2/2 contact lens wear; pseudomonas or acanthamoeba
Pt: Pain, reduced vision, tearing, photophobia, conjunctival erythema
(same as keratitis)
Dx:
Ciliary injection (limbic flush), corneal ulceration on slit lamp exam
Hazy cornea, ulcer
Tx: Fluoroquinolone gtt: Ciprofloxacin, vigamox
Do NOT patch eye!!
Keratitis Path: Pt: Dx: Tx:
Path: Inflammation of the cornea
HSV, fungal
May rapidly progress and be sight-threatening
Pt: Pain, reduced vision, tearing, photophobia, conjunctival erythema (same as corneal ulcer)
Dx: HSV: Dendritic lesions-> branching seen with fluorescein staining
Tx:
Topical antivirals: trifluridine, vidarabine, ganciclovir ointment
PO acyclovir
Pterygium Path: Pt: Dx: Tx:
Path: Localized fibrovascular tissue due to chronic exposure to UV light
Pt: Asx-> obstructs vision when crosses pupil
MC on nasal side of eye
Dx: Fleshy, triangular-shaped “growing” fibrovascular mass
Tx: Removal only if growth affects vision
Dacryocystitis
Path:
Pt:
Tx:
Dacryoadenitis
Path: Infection of the lacrimal sac S aureus (MC), GABHS, S epidermidis, H flu, S pneumo
Pt:Tearing, redness to medial cantonal (nasal side) of lower lid
Tx:
Abx-> clinda, vanc + ceftriaxone
Chronic-> dacryocystorhinostomy
Dacryoadenitis: inflammation of lacrimal gland; swelling of outer portion of upper eyelid
Blepharitis
Path:
Pt:
Tx:
Path: Inflammation of eyelid margins (bilateral)
S aureus
Pt: Crusting, scaling, red-rimming of eyelids and eyelash flaking
Tx:
Eyelid hygiene
+/- abx: erythromycin, bacitracin, sulfacetamide
Chalazion
Path:
Pt:
Tx:
Path: Painless granuloma of internal meibomian sebaceous gland-> focal eyelid swelling
Pt: Nontender eyelid swelling
Tx:
Eyelid hygiene, warm compresses
If affecting vision-> corticosteroid injection or incision and curettage
Ectropion
Path:
Pt:
Tx:
Path: Eyelid and lashes turn outward 2/2 relaxation of orbicularis oculi muscle
Elderly, bilateral
Pt: Irritation, ocular dryness, tearing, sagging of eyelid
Tx:
Surgical correction if needed
Lubricating eye drops
Entropion
Path:
Pt:
Tx:
Path: Eyelid and lashes turned inward 2/2 spasm of orbicularis oculi muscle
Elderly
Pt: Eyelashes may cause corneal abrasion/ulcerations, erythema, tearing
Tx:
Surgical correction if needed
Lubricating eye drops
Hordeolum
Path:
Pt:
Tx:
Path: Local abscess of eyelid margin
S aurea
External: near lid margin (eyelash follicle or external sebaceous gland infection)
Internal: meibomian gland infection
Pt: Painful, warm, swollen red lump on eyelid
Tx:
Warm compresses +/- topical abx (erythromycin, bacitracin)
+/- I&D if no spontaneous drainage after 48hrs
Peripheral vs Central vertigo onset: duration: intensity: effect on head position: direction of nystagmus: any neurologic findings: any auditory findings: path:
Peripheral / Central onset: sudden / gradual or sudden duration: sec-min / variable intensity: severe / mild effect on head position: worsened by position / minimal change direction of nystagmus: unidirectional (never purely vertical) / horizontal, vertical rotary, & bidirectional any neurologic findings: no / often any auditory findings: occasionally / no
Path:
Peripheral-> horizontal nystagmus
-Benign positional vertigo (BPV): episodic vertigo, no hearing loss
-Meniere: episodic vertigo + hearing loss
-Vestibular neuritis: continuous vertigo, no hearing loss
-Labyrinthitis: continuous vertigo + hearing loss
-Cholesteatoma
Central -> vertical nystagmus, + CNS signs, gradual onset Cerebellopontine tumors Migraine Cerebral vascular accident Multiple sclerosis Vestibular neuroma
Benign Paroxysmal Positional Vertigo Path: Pt: Dx: Tx:
Path: Displaced otoliths
Pt: Sudden, episodic peripheral vertigo provoked by changes of head position
Dx: + Dix-Hallpike test -> fatigable horizontal nystagmus
Tx: Epley maneuver
Vestibular Neuritis and Labyrinthitis Path: Pt: Dx: Tx:
Path:
- Vestibular neuritis: inflammation of vestibular portion of CN 8 (MC after viral infection)
- Labyrinthitis: vestibular neuritis + hearing loss/tinnitus (cochlear involvement)
Pt:
Vestibular sx: peripheral vertigo (continuous), dizziness, N/V
Cochlear sx (labyrinthitis): hearing loss
Tx:
Corticosteroids
sx: meclizine, benzos
Meniere’s Disease Path: Pt: Dx: Tx:
Path: Idiopathic distention of end-lymphatic compartment of inner ear by excess fluid
Pt: Episodic vertigo-> mins-hrs Tinnitus Ear fullness Hearing loss
Dx: Transtympanic electrocochleography most accurate test during active episode
Tx:
Sx: meclizine, benzos
Decompression if refractory to meds or severe
Prevent: diuretics (HCTZ), avoid salt, caffeine, chocolate, ETOH
Acoustic (vestibular) neuroma Path: Pt: Dx: Tx:
Path: Cranial nerve VIII/8 schwannoma
Pt:
Unilateral sensorineural hearing loss is acoustic neuroma until proven otherwise
Tinnitus
Dx: MRI Usually unilateral If bilateral-> neurofibromatosis type II CT
Tx: Surgery or focused radiation therapy
Optic neuritis Path: Pt: Dx: Tx:
Path: Acute inflammatory demyelination of optic nerve (CN II) Multiple sclerosis (MC), meds: ethambutol, chloramphenicol
Pt: Loss of color vision, central scotoma/blind spot, loss of vision over a few days, unilateral
Dx:
Marcus-Gunn pupil: afferent pupillary defect-> during swinging-light test from the unaffected eye into the affected eye, the pupils appear to dilate
Fundoscopy:
-2/3: normal disc/cup (retrobulbar neuritis
-1/3: + optic disc swelling/blurring (papillitis)
Tx:
IV methylprednisolone followed by oral steroids
Vision usually returns w/ tx
Papilledema Path: Pt: Dx: Tx:
Path: Optic nerve (disc) swelling 2/2 inc ICP (classically bilateral)
Idiopathic intracranial HTN, space occupying lesions, inc CSF production, cerebral edema
Pt: HA, N/V, vision usually well preserved but may have changes
Dx:
- Fundoscopy: swollen optic disc w/ blurring margins
- MRI/CT to R/O mass effect prior to LP
Tx: Diuretics-> acetazolamide (dec. production of aqueous humor and CSF)
Orbital cellulitis Path: Pt: Dx: Tx:
Compare to preseptal cellulitis
Path: H flu, S pneumo, S aureus
Sinusitis, dental infections, facial infections
Pt: Decreased vision, pain with ocular movements
Proptosis
Dx: High resolution CT: infection of the fat and ocular muscles
Tx:
IV abx-> vanc, clinda, cefotaxime, amp/sulbactam
Preseptal cellulitis:
- Infection of eyelid and periocular tissue
- No visual changes and no pain with ocular movement
- Tx: amoxicillin
Macular degeneration Path: Pt: Dx: Tx:
Path:
- risk factors: Age >50, white, female, smokers
- MC cause of permanent legal blindness and vision loss in elderly
- Macula fn-> central vision and detail and color vision
Pt:
Insidious onset
Gradual central vision loss, painless
Metamorphopsia: straight lines appear bent
Dry (atrophic) Dx: -Amsler grid Tx: -Monitor with amsler grid -Zinc, vit A C and E may slow progression
Wet (neovascular or exudative) Dx: -Fluorescein angiography Tx: -Intravitreal anti-angiogenic (bevacizumab) -Laser photocoagulation -Monitor with optical tomography
Retinal detachment Path: Pt: Dx: Tx:
Path:
Rhegmatogenous (MC type): retinal tear-> retinal inner sensory layer detaches fro choroid plexus
-Risk factors: myopia (near sighted), cataracts
Traction: adhesion separate the retinal from its base
-Proliferative DM retinopathy, sickle cell, trauma
Exudative (serous): fluid accumulates beneath retina-> detachment
-HTN, CRVO, papilledema
Pt: Photopsia (flashing lights) -> floaters -> regressive unilateral vision loss: shadow “curtain coming down” in periphery -> central vision loss
Dx: Fundoscopy
- Retinal tear
- +Shafer’s sign: clumping of brown-colored pigment cells in anterior vitreous humor resembling “tobacco dust”
Tx:
Ophtho emergency!! Do NOT use miotic drops; keep pt supine
Laster, cryotherapy, ocular surgery
Retinopathy
Path:
Path: Diabetic retinopathy: retinal blood vessel damage -> retinal ischemia, edema -> capillary well breakdown
Nonproliferative (background): microaneurysms (not associated with vision loss)
-Cotton wool spots (soft exudates): fluffy grey-white spots- nerve layer micro infarctions
-Hard exudates: yellow spots w/ sharp margins often circinate; seen in HTN and DM retinopathy
Tx:
-Panlaster tx
-Strict glucose control
Proliferative: neovascularization
Tx: VEGF inhibitors (bevacizumab), laser photocoagulation, tight glucose control
Maculopathy: macular edema or exudates, blurred vision, central vision loss
Tx: laser
Corneal abrasion
Pt:
Dx:
Tx:
Pt: Foreign body sensation, tearing, red and painful eye
Dx:
- Pain relieved with ophthalmic analgesic drops
- Fluorescein staining: corneal abrasion-> “ice rink”/linear abrasions; evert eyelid to look for object
Tx:
Check visual acuity
Foreign body removal with saline irrigation
Corneal abrasions:
-Patching not indicated for small abrasions
-Do not patch eye in contact lens wearers -> pseudomonas; start fluoroquinolone gtts
Abx: topical erythromycin, polymyxin/trimethoprim, sulfacetamide, cipro
Orbital floor "blowout" fracture Path: Pt: Dx: Tx:
Path: Fracture of bones of eye socket
Blunt blow 2/2 large object-> fist, baseball bat
Pt:
Pain, tenderness, swelling, diplopia
Decreased visual acuity
Orbital emphysema
Dx: CT scan may show “teardrop” sign
Tx:
- Nasal decongestants (dec pain), avoid blowing nose
- Steroids reduce swelling
- Abx: amp/sulbactam, clinda
- Surgery
Globe rupture Path: Pt: Dx: Tx:
Path: Outer membranes of eye disrupted by blunt/penetrating trauma
Ophtho emergency!!
Pt:
Diplopia
Ocular pain (may be painless)
Dx:
Markedly reduced visual acuity
Prolapse of ocular tissue from sclera or corneal opening
Enophthalmos: recession of globe within the orbit)
+Seidel’s test: parting of fluorescein dye by a clear stream of aqueous humor from anterior chamber
Teardrop or irregularly shaped pupil, hyphema
Tx:
Rigid eye shield; impacted object left undisturbed
Immediate ophtho consult
Hyphema: place at 45 degrees (keep RBCs from staining cornea)
Hyphema
Path:
Pt:
Tx:
Path: Blunt trauma to globe
Pt: Blood in anterior chamber of eye
Tx:
Check vision
Patch eye
Refer ophtho ASAP!
Retinal artery occlusion Path: Pt: Dx: Tx:
Path: Athereosclerotic disease
Ophtho emergency!!
Pt: Sudden, painless, unilateral vision loss
Dx:
Pale retina with cherry red-colored fovea
“Box car” appearance
Tx:
Refer ASAP; poor prognosis
Decrease IOP: acetazolamide, chamber paracentesis
Revascularization: place pt supine + orbital massage orbit to dislodge clot
Retinal vein occlusion Path: Pt: Dx: Tx:
Path: Fluid back up in retina
Risk factors: DM, HTN, glaucoma, hypercoagulable states
Pt: Sudden, painless, unilateral vision loss
Dx:
Extensive retinal hemorrhages: Blood and thunder
Relative afferent pupillary defect
Tx:
No known effective tx
Anti-Inflammatories, steroids, laser photocoagulation
May resolve spontaneously or progress to permanent vision loss
Amaurosis fugax
Path:
Pt:
Path:
Vision loss with complete recovery
Retinal emboli/ischemia; TIA, giant cell arteritis, SLE
Pt: Vision loss (mins) “curtain” resolves “lifts up” within 1 hour
Narrow angle-closure glaucoma Path: Pt: Dx: Tx:
Path: Decreased drainage of aqueous humor via trabecular meshwork and canal of Schlemm
Inc intraocular pressure-> optic nerve damage -> dec visual acuity
Ophtho emergency!!
Pt:
Precipitating factors: mydriasis (pupillary dilation) from dim lights, sympathomimetics and anticholinergics
Severe, sudden, unilateral ocular pain
N/V/HA
Intermittent blurring of vision; halos around lights
Peripheral vision loss (tunnel)
Dx:
Inc intraocular pressure by tonometry (>21 mmHg)
Fundoscopy-> cupping of optic nerve
Tx:
Lower IOP (acetaxolamide, BB, mannitol)
Open the angle (cholinergics-> pilocarpine, carbachol)
Peripheral iridotomy definitive tx
Open-angle glaucoma Path: Pt: Dx: Tx:
Path: Slow, progressive bilateral peripheral vision loss
Risk factors: Af-Am, age >40, family hx, DM
Pt:
Gradual bilateral painless peripheral vision loss (tunnel vision) -> central loss
Asx until later in disease course
Dx: Cupping of optic disc, notching of disc rim
Tx:
Prostaglandin analogs: latanoprost, timolol, brimonidine, acetazolamide
Laser therapy (trabeculoplasty) if medical therapy fails
Strabismus Path: Pt: Dx: Tx:
Path: Misalignment of eyes
Esotropia: convergent strabismus, deviated inward
Exotropia: divergent strabismus, deviated outward
Pt: Diplopia, scotomas (blind spot in normal visual field), amblyopia (lazy eye)
Dx:
Hirschberg corneal light reflex
Cover-uncover test
Tx:
Patch therapy: normal eye is covered
Corrective surgery: if unresponsive to conservative therapy
Acute sinusitis Path: Pt: Dx: Tx:
Path: S pneumo, H flu, GABHS, M cat
Acute = 1-4 weeks
Pt:
Sinus pain/pressure, Maxillary MC
HA, purulent sputum, nasal d/c
Dx: Sinus tenderness Opacification with transillumination Clx: sx should be present >1w CT > XR (water’s view)
Tx:
Sx present for >10-14 days (earlier if facial swelling, fever)
Amoxicillin (1st line)
2nd: doxy, bactrim
Leukoplakia
Path:
Pt:
Tx:
Path: Precancerous, hyperkeratosis due to chronic irritation-> tobacco, cigarette smoking, , ETOH, dentures
Pt: Painless white patchy lesions the CANNOT be scraped off
Tx:
Cryotherapy, laser ablation
Bx to assess cancer risk
Oral Hairy Leukoplakia
Path:
Pt:
Tx:
Path: Epstein-Barr Virus (HHV-4)
MC in immunocompromised
Pt:
Painless, white plaque along the LATERAL TONGUE BORDERS or BUCCAL MUCOSA +/- smooth/irregular “hairy” or “feathery” lesions w/ prominent folds or projections. Appearance can change daily but CANNOT be scraped off
Tx:
May spontaneously resolve
Antiretroviral tx, ablation
Ludwig's angina Path: Pt: Dx: Tx:
Path: Cellulitis of the sublingual and submaxillary spaces in the neck
MC 2/2 dental infections
Pt: Swelling and erythema of upper neck and chin w/ pus on the floor of the mouth
Dx: CT
Tx: Abx: amp/sulbactam; penicillin + metronidazole or clinda
