ENT and Eye Flashcards
Causes of acute otitis externa
If there is copious purulent or serous drainage (crusty) - likely a bacterial cause (Pseudomonas or Staph) - Swimmer’s Ear
If gray/black plaques with a fuzzy cotton appearance - likely fungal - diabetics get this
Treatment of Acute Otitis Externa
Cleaning the ear is just as affective as antibx treatment
–1:1 dilution of 3% hydrogen peroxide
If bacterial AOE is suspected can also give Cipro/hydrocortison gtts or Floxin gtts
Diagnostic features of acute otitis media
Ear pain with some URI sxs
Real diagnosis comes from TM bulging, not just erythema
AOM with effusion - crackling sound in ear caused by blocked eustation tube - will be able to see the fluid behind the TM, no bulging
Perforated TM - severe AOM or trauma
–Severe pain, vertigo, tinnitus, markedly decreased hearing
–Start antibx, call ENT
Treatment of Acute Otitis Media
Usually caused by Streptoccocus sp.
Treat with Amoxicillin
–Can use Erythromycin if penicillin allergy
Treatment of perforated tympanic membrane
Remove debris with gentle suction
Insert a sterile cotton ball into the ear canal to protect it and have patient use wax ear plugs when showering
ENT should be the ones to remove the cotton ball
Treat with Floxin gtts
Mastoiditis and how it is diagnosed and treated
Presents with sxs of AOM but also has fever, headache, possible signs of sepsis.
Tender mastoid process
Diagnosed with MRI
Treat with Ceftriaxone IV given that it is usually caused by Staph, Strep or H influenzae
Consult ENT
Working someone up for dizziness, specifically vertigo
Hintz exam can diagnose vertigo
If sxs are severe (vomiting, falling, spinning) - likely peripheral (disorder of the inner ear)
CNS problems usually cause more mild sxs
Monitor for nystagmus - horizontal nystagmus usually suggests peripheral cause. Other types of nystagmus are caused by central.
Can perform the Dix-Hallpike test to provoke sxs on a patient that is not currently experiencing vertigo
Treatment can be with meclizine for a few days
If the response is poor, should receive MRI to rule out CNS lesion
Epistaxis Treatment
-Clamp or pinch nose closed
-Put cotton ball with lidocaine and vasoconstrictor (oxymetalozine) into nose
-Look for bleeding in nose with nasal speculum
-Use bayonet foceps to insert medicated pledget to vasoconstrict
-Then reapply pressure for 15 minutes
-Could also consider silver nitrate or Merocel sponge
-Have patient walk around for a few minutes to increase intracranial pressure and reassess for bleeding
-If you are leaving packing in, start patient on cephalexin or clindamycin to prevent sinusitis.
Clinical features of Ludwig’s Angina
Type of severe cellulitis involving the floor of the mouth with rapid onset over hours
Early on, the floor of the mouth is thrust upward and there is difficulty swallowing saliva
Usually has trismus (pain with opening mouth) and hot potato voice, febrile
As the condition worsens, the airway may be compromised
Obtain CT neck and soft tissues with contrast to find the abscess
Difference between bacterial and viral pharyngitis
Centor Criteria for bacterial pharyngitis (3 or more indicate high risk for bacterial):
-Rapid onset fever
-Tonsillar exudates
-Tender anterior cervical adenopathy
-Absence of cough
Viral:
-Slower onset of sore throat
-Nasal congestion
-Cough
-Aphthous ulcers on the palate
-Conjuctivitis
-Other symptoms usually precede the onset of the sore throat
Treatment of bacterial pharyngitis
Penicillin V 500mg PO BID x10 days
Clinical features of peritonsillar abscess
The patient complaints of usual sxs of bacterial pharyngitis plus:
-Hot potato voice
-Drooling or dysphagia
-Trismus
-Putrid breath
-Trouble breathing
Only one tonsil will be affected - no such thing as bilateral peritonsillar abcess
Treatment of Peritonsillar abscess
Obtain a CT of the neck with contrast if abscess is difficult to see
Consult ENT
Treated with ampicillin sulbactam 3mg IV every 8 hours
Clindamycin for PCN allergy
Retropharyngeal abscess and what can go wrong
Typically, pt complains of sore throat, difficulty swallowing and dysphagia
Obtain neck CT soft tissues with contrast and consider CT chest as well given concern for mediastinitis
Likely will need intubation given threat to airway but endotrachial intubation might be impossible because it could rupture the abscess, might need surgical airway
Consult ENT
Surgery will be needed to drain the abscess.
What is blepharitis and how is it treated?
Common chronic bilateral inflammatory condition of the lid margins
Can be caused by use of old make up or false lashes
Usually better hygiene resolves the problem however can treat with minocycline, tetracycline or docycycline
If no exudate then you don’t need antibx
Dacrocystis: What is it and treatment
Infection of the lacrimal sac due to an obstruction of the nasolacrimal drainage system
Presents as painful, swelling, redness and tenderness to the lacrimal sac
Usually responds well to systemic, not topical antibx
Treatment of bacterial conjuctivitis
Erythromycin ointment
If they wear contacts, higher risk for Pseudomonas so need to treat with Cipro
Clinical features of uveitis
Almost always monocular
Usually complain of eye pain, blurriness of vision, photophobia and maybe some injection for the last few days
Instillation of anesthetic eye drops will usually have little to no effect
Look for limbal flush - red rim around the cornea as this is an early sign of uveitis
Look for irregular shape of the pupil
Consensual photophobia is also noted
Shining a light across the anterior chamber will show a “smokey room” which is the aqueous humor filling with exudate
How to treat Uveitis
Measure intraocular pressure with a Tonopen
–Should be normal or low.
–If high, should consider acute glaucoma
Treatment is ophthalmology consult and treatment with Cyclopentolate 1% - paralyses the pupil and keeps iris away from the lens so that adhesions do not form
Also treat with prednisolone 1% 1gtt QID
Needs follow up in 24 hours
Clinical progression of retinal detachment
-Flashes of light briefly on the periphery
-Sudden dramatic increase in the number of floaters
-A ring of floaters or hairs just to the temporal side of the central vision
-A dense shadow that starts in the peripheral vision and slowly progresses towards the central vision
-The impression that a veil or curtain was drawn over the field of vision
-Straight lines that suddenly appear curved (positive Amsler grid test)
-Central visual loss
Vitreous hemorrhage: presentation, treatment
Rupture of a blood vessel within the choroid can result in hemorrhage spreading under the sensory retina
Pt reports flashes and floaters, blurry vision, reddish tint to vision (suggests blood as mixed into the vitreous) or a reddish spot in the field of vision (suggests a contained hemorrhage)
Refer to ophthalmologist immediately
Glaucoma: Acute vs chronic
Chronic, open angle glaucoma is caused by the decrease in flow of aqueous humor through the trabecular meshwork due to degeneration and obstruction of the meshwork.
This causes chronic, painless buildup of pressure in the eye that can be measured with a Tonopen
Cupping of the disc
Constriction of visual fields
Acute, closed-angle glaucoma is caused by sudden forward displacement of the iris against the cornea (often caused by medications that dilate the pupil) that causes an acute build up of aqueous humor
This is very painful, causing vomiting, blurred vision, halos around lights
Treatment of acute glaucoma
Chronic:
Prostaglandin analogs: end in -prost
Alpha 2-adrenergic agonists
Acute:
Single dose of Acetazolamide 500mg IV followed by 250mg PO QID
If no response, sometimes osmotic diuretics are needed such as Mannitol 1-2g/kg
Any medicine that has a mydriatic effect needs to be stopped at once (any medicine with anticholinergic effects)
Risk factors for acute glaucoma
Diabetes
Can also be caused by medications that cause mydriasis - anticholinergics
Difference between dry and wet macular degeneration
Dry form (nonexudative) is more common and less severe - chronic over years
–Cellular debris called drusen accumulates between the retina and the choroid, causing atrophy and scarring to the retina
Wet form (exudative) is less common and quite severe - acute change over weeks
–Blood vessels grow up from the choroid behind the retina which can leak exudate and fluid and also cause hemorrhaging
Difference between central retinal vein occlusion and branch retinal vein occlusion
More common than artery occlusions and less severe
Central retinal vein occlusion - main vein of the eye is blocked, therefore causes hemorrhages in the retina - whole retina is bleeding
Brain retinal vein occlusion - a small branch of vessels attached to the main vein is blocked, causing bleeding in just parts of the retina - cotton wool exudates
Orbital blowout fracture exam findings
Common symptoms include:
_Orbital pain
-Limitations of gaze, referred to as entrapment
-Diplopia
-Sunken ocular globes
-Loss of sensation of the cheek and upper gums due to infraorbital nerve injury
What do cotton wool spots indicate
Diabetic retinopathy
What causes arcus senilis
Old age and HLD
What do you do with bright red eye that is irritated with hx of herpes simplex?
Refer to ophthalmologist - emergency!
What do you do with an eye that is red with copious purulent drainage?
Could be Gonococcal/Chlamydial conjunctivitis
Ceftriaxone 250mg IM + Azithromycin
How do you treat a corneal abraison
Anesthetize the eye for thorough exam to ensure no foreign body
Topical antibiotic ointment may be prescribed, especially in patients who wear contact lenses (pseudomonas)
Steroid drops and anesthetic drops are contraindicated after initial exam
Should be healed in 24 hours
What is the pathophysiology of a cataract
Clouding and opacification of the normally clear lens of the eye
Highest cause of treatable blindness
What are the symptoms of cataracts
Painless
Clouded, blurred or dim vision
Difficulty with vision at night
Sensitivity to light and glare
Fading/yellowing of colors
Halos around lights
No red reflex
Diplopia in a single eye
