ENOT and Ophthalmology Flashcards
What is acute laryngitis?
inflammation of the larynx, usually from virus/overuse
- change in voice (decreased volume/hoarse)
- consider cell carcinoma if hoarseness persists > 2 weeks, history of ETOH/smoking
- consider GERD if no associated viral etiology
- M. cat, H. flu
How is acute laryngitis dx?
clinical, laryngoscopy required for sx persisting > 3 weeks
-deviation of soft palate = abscess
How is acute laryngitis tx?
symptomatic (cough suppressant, voice rest, steam inhalant)
- viral = self-limiting, oral and IM steroids for vocal performers to hasten recovery
- bacterial - erythromycin, cefuroxime, or augmentin for cough or hoarseness
What is a hyphema?
trauma causes blood in the anterior chamber of the eye (between the cornea and the iris) and may cover iris
- the blood may cover part or all of the iris (the colored part of the eye) and the pupil, and may partly or totally block vision in that eye
- usually from blunt/penetrating trauma = ensure no other type of injury (skull fracture, orbital fracture)
How is hyphema dx?
orbital CT if indicated + ophthalmology consult
What is the tx of hyphema?
usually, blood is reabsorbed over days/weeks
- elevate head at night at 30 degrees, acetaminophen for pain, patch/shield
- may use beta-adrenergic blockers or carbonic anhydrase inhibitors
- surgery if high pressure/persistent bleeding
- NSAIDs contraindicated (may increase bleeding)
What is acute otitis media?
the clinical diagnosis of AOM requires 1) bulging of the tympanic membrane or 2) other signs of acute inflammation (eg marked erythema of the tympanic membrane, fever, ear pain) and middle ear effusion
What are the characteristics of acute otitis media?
- bugs: s. pneumonia 25% H. influenzae 20%, M. catarrhalis 10%
- acute: < 3 weeks, chronic >3 mo, recurrent: 3 episodes in 6 mo or 4 in 12 with clearing between
- chronic > 3 mo: clear serous fluid in the middle ear without s/sx of ear infection (may have hearing loss/asymptomatic) - no abx
How is acute otitis media dx?
otoscopic = bulging, loss of landmarks, redness, TM injection
-a key finding is limited mobility of the TM with pneumotoscopy
What is the tx for acute otitis media?
first- line amoxicillin, augmentin = 2nd line (PCN allergy = azithromycin, erythromycin, Bactrim)
- treat < 2 y for 10 days and > 2 y for 5-7 days
- recurrent: tympanovstomy, tympanocentesis, myringotomy
- complications: mastoiditis and bulluous myringitis
What is labyrinthitis?
acute severe vertigo, hearing loss (several days to a week), tinnitus; vertigo progressively improves, hearing loss may not resolve, usually preceded by viral respiratory illness
How is labyrinthitis dx?
clinical - an absence of neurological deficits
What is the tx for labyrinthitis?
- antibiotics indicated with fever or signs of bacterial infection
- vestibular suppressants - meclizine (lorazepam, clonazepam) are helpful during initial acute symptoms
What is bacterial acute pharyngitis?
Usually GAS - group A strep
- centor criteria: fever > 38 (100.4 F), anterior lymphadenopathy, lack of cough, pharyngotonsillar exudate
- If 3 out of 4 centor criteria are met get a rapid streptococcal test (sensitivity >90%)
- dx: throat culture = gold standard; think rheumatic fever/glmoerulonephritis
- s/sx: fever, sore throat, no cough, exudates, cervical LAD
- tx: penicillin to prevent acute rheumatic fever (erythromycin with allergy)
What is viral pharyngitis?
less likely exudative (CMV, EBV, adenovirus)
- mononucleosis (caused by Epstein Barr virus) - rash with penicillins
- Dx: atypical lymphocytes + heterophiles agglutination test (mono spot)
- splenomegaly = splenic rupture possible with contact sports
- for athletes planning to resume non-contact sports three weeks from symptom onset
- for strenuous contact sports four weeks after illness onset
- tx: supportive
What is fungal acute pharyngitis?
common to pt with inhaled steroids
- s/sx: sore throat, dysphagia, white patches in the oropharynx, seen in HIV pt
- dx: clinical/endoscopy
- tx: clotrimazole troches, miconazole, nystatin swish, fluconazole
What is macular degeneration?
gradual painless loss of central vision
- the macular is responsible for central visual acuity which is why macular degeneration causes gradual central field loss
- (versus glaucoma which presents with a peripheral = central loss)
What is dry vs. wet macular degeneration?
- dry (85% of cases): atrophic changes with age - a slow gradual breakdown of the macular (macular atrophy), with drusen (dry) = yellow retinal deposits
- wet = an advanced form of dry age-related macular degeneration
- new blood vessels growing beneath the retina (neovascularization) leak blood and fluid, damaging the retinal cells
- these small hemorrhages usually result in rapid and severe vision loss
How is macular degeneration dx?
dilated funduscopic findings are diagnostic = hemorrhage or fluid in the sub retina; macular grayish-green discoloration; Amsler grid = distortion on Amsler grid
What is the tx of macular degeneration?
wet age-related macular degeneration -VEGF inhibitors (e.g becaxizumab) -photodynamic therapy -zinc and antioxidant vitamins dry age-related macular degeneration -zinc and antioxidant vitamin
What is acute sinusitis?
often follows URI - can be viral or bacterial (bacterial = S. pneumonia, H. influenzas, M. catarhalis)
- risk factors: cigarette smoke/exposure, history of trauma, presence of foreign body
- purulent nasal discharge, facial pain and pressure, nasal obstruction, fever
- tenderness to palpation over the affected sinus, decreased ligh transmission with transillumination
How is acute sinusitis dx?
clinical, XR not recommended, MRI indicated if malignancy or intracranial spread of infection is suspected
What is the tx for acute sinusitis?
NSAIDs for pain, saline washes, steam, oral/nasal decongestants - improvement in 2 weeks
- Indications for antibiotics in rhino sinusitis include the duration of symptoms > 10 days without improvement, treatment five to seven days
- amoxicillin (500 mg orally three times daily or 875 mg twice daily) or amoxicillin-clavulanate (500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily)
- pencillin-allergic: doxycycline 100 mg orally twice daily or 200 mg orally daily
- macrolides (clarithromycin or azithromycin) and trimethoprim-sulfamethozaole are not recommended for empiric therapy because of high rates of resistance of S. pneumoniae
- kids amoxicillin x 10-14 days
What is mastoiditis?
suppurative infection of mastoid air cells = usually a complication of acute otitis media
- organisms: s. pneumonia, H. influenzas, M. catarrhalis, S. aureus, S. pyrogens
- fever, otalgia, pain, erythema posterior to ear and forward displacement of the external ear
How is mastoiditis dx?
clinical, CT scan temporal bone with contrast for complicated/toxic appearing
What is the tx of mastoiditis?
simple = oral antibiotics, IV antibiotics (ceftriaxone)
- ENT referral in more serious cases or pt with unreliable follow up
- drainage of middle ear fluid
What is allergic rhinitis?
clear nasal drainage, rhinorrhea, itchy, watery eyes, sneezing nasal congestion, pale, bluish boggy mucosa
- allergic shines (blue discoloration below eyes), transverse nasal verses
- IgE mediated mast cell histamine release
What is the tx of allergic rhinitis?
avoid any known allergens and use antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline drops or washes, and immunotherapy
-Intranasal decongestants not be used more than 3-5 days may cause rhinitis medicamentosa
What are the ddx of nasal congestion?
seasonal allergies, common cold, sinusitis, upper respiratory infection, animal allergy, etc.
What is barotrauma?
tissue injury caused by a pressure-related change in body compartment gas volume - affects air-containing areas (lungs, ears, sinuses, GI tract, air spaces in teeth, space in diving face mask)
-barotrauma presents with ear pain and hearing loss that persists past the inciting event = sinus pain, epistaxis, abdominal pain/dyspnea, and LOC
How is barotrauma dx?
clinical but sometimes needs imaging tests; exam: signs of trauma without signs of infection (redness without building pus, or effusion)
What is the tx of barotrauma?
supportive (anti-inflammatories) then consider prophylaxis
-pseudoephedrine or Afrin can be good for prophylaxis (not be used for > 3 days - you must be careful when recommending this to divers, depending on dive times
What is optic neuritis?
acute inflammation and demyelination of the optic nerve leading to acute monocular vision loss/blurriness and pain on extraocular movements
- typically occurs over hours to days
- associated with multiple sclerosis = MC cause and initial presenting symptoms
- can also be from ethambutol
How is optic neuritis dx?
fundoscopy: inflammation of the optic disc, confirmed by MRI
What is the tx of optic neuritis?
corticosteroids (methylprednisolone IV)
-refer to neurology for evaluation of Multiple Sclerosis
What is blepharitis?
chronic inflammation of lid margins caused by seborrhea, staph, or strep = dysfunction of Meibomian glands
What are the characteristics of blepharitis?
- anterior blepharitis: eyelid skin, eyelashes; may be ulcerative (s. aureus) or seborrheic
- posterior: inflammation of Meibomian gland; may be infectious (s. aureus) or caused by glandular dysfunction
- crusting, scaling, red-rimming of the eyelid and eyelash flaking, adherent eyelashes, hyperemic lid margins, dandruff-like deposits (scurf) and fibrous scales (collarettes); clear or slightly injected conjunctiva; thick cloudy discharge visible when Meibomian glands obstructed
How is blepharitis dx?
usually by slit-lamp examination
What is the tx of blepharitis?
warm compresses, daily lid wash with diluted baby shampoo on cotton-tipped swabs; lid massage to express the gland; topical antibiotics used if infection suspected
What is orbital cellulitis?
infection of orbital muscles and fat behind the eye (periorbital = infection only of skin)
- decreased extraocular movement, pain with movement of the eye and proptosis, signs of infection
- often associated with sinusitis, occurs more often in children than adults - ages 7-12 y/o
- decreased vision is a rare manifestation of orbital cellulitis
How is orbital cellulitis dx?
CT scan of orbits (confirmatory)
- focused assessment on extraocular muscles
- CBC and blood cultures in some settings
What is the tx of orbital cellulitis?
hospitalization and IV broad-spectrum antibiotics (vancomycin)
What is a blowout fracture?
history of blunt trauma, muscle entrapment, eyelid swelling, gaze restriction, double vision, decreased visual acuity, enophthalmos (sunken eye)
- pain with EOM, epistaxis, erythema/ecchymosis, “raccoon eyes”
- anesthesia/paresthesia in the gums, upper lips, and cheek indicate damage to the infraorbital nerve
What is the tx for a blowout fracture?
prompt ophthalmic referral = treatment with surgery
-antibiotics to prevent infection
What is bacterial otitis externa?
“swimmer’s ear”
- ear pain (especially with movement of tragus or auricle) pain with eating, purulent cheesy white discharge, palpation of tragus is painful
- tuning fork = bone conduction > air conduction
- pseudomonas aeruginosa (swimmer’s ear), S. aureus (digital trauma)
- malignant otitis externa is commonly seen in diabetics
What is the tx of bacterial otitis externa?
antibiotic drops = (aminoglycoside or fluoroquinolone +/- corticosteroids) + avoid moisture
- if perforated or chance of perforation: ciprofloaxacin 0.3% and dexamethasone 0.1% suspension: 4 drops BID x 7 days or ofloxacin: 0.3% solution 10 drops once a day x 7 days
- diabetic/immunocompromised: malignant otitis externa = necrotizing infection = hospitalization with IV abx (caused by aspergillus)
What is fungal otitis externa?
- prititus, weeping, pain, hearing loss
- swollen, moist, wet appearance
- aspergillus niger (black), A. flavus (yellow) or A. fumigatus (gray), Candida albicans
What is the tx of fungal otitis externa?
topical therapy, anti-yeast for candida or yeast: 2% acetic acid 3-4 drops QID, clotrimazole 1% solution, itraconazole oral