EENT Flashcards by Kelsey Burkhart

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

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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

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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!!

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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